Provider Demographics
NPI:1093940082
Name:WATERSMITH, LORI KAY
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:KAY
Last Name:WATERSMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:KAY
Other - Last Name:WATERSMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:THERAPIST
Mailing Address - Street 1:2329 NE 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-1364
Mailing Address - Country:US
Mailing Address - Phone:503-846-1732
Mailing Address - Fax:
Practice Address - Street 1:1778 NE CORNELL RD
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-2740
Practice Address - Country:US
Practice Address - Phone:503-648-6621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR985865172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker