Provider Demographics
NPI:1073961983
Name:SMITH, MICHELLE (PSYD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1728 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-2737
Mailing Address - Country:US
Mailing Address - Phone:503-357-6171
Mailing Address - Fax:
Practice Address - Street 1:1728 MAIN ST
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2737
Practice Address - Country:US
Practice Address - Phone:503-357-6171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3574103TC0700X, 103TC2200X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical