Provider Demographics
NPI:1114479599
Name:SMITH, AMY C (CADC II, CRM)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:C
Last Name:SMITH
Suffix:
Gender:F
Credentials:CADC II, CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 SW CEDAR HILLS BLVD STE 170
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2020
Mailing Address - Country:US
Mailing Address - Phone:503-626-1800
Mailing Address - Fax:
Practice Address - Street 1:3800 SW CEDAR HILLS BLVD STE 170
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2020
Practice Address - Country:US
Practice Address - Phone:503-626-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-01
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21-01-10037101Y00000X, 101YA0400X
OR23-CRM-1940175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR16-07-17OtherMHACBO CADC-I
OR23-CRM-1940OtherMHACBO CRM
OR500717291Medicaid
OR21-01-10037OtherMHACBO CADC-II