Provider Demographics
NPI:1275933020
Name:SMITH, RENE
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4207 N GANTENBEIN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-2903
Mailing Address - Country:US
Mailing Address - Phone:831-333-9469
Mailing Address - Fax:
Practice Address - Street 1:107 SE WASHINGTON ST
Practice Address - Street 2:134
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2103
Practice Address - Country:US
Practice Address - Phone:503-239-2639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19662225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist