Provider Demographics
NPI:1386038065
Name:SMITH, EVAN (LMT)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5530 ADAMS RD
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540-7701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5530 ADAMS RD
Practice Address - Street 2:
Practice Address - City:TALENT
Practice Address - State:OR
Practice Address - Zip Code:97540-7701
Practice Address - Country:US
Practice Address - Phone:541-864-0182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-20
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20987225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist