Provider Demographics
NPI:1518339316
Name:SMITH, AMY (LMT #13580)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT #13580
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7803 SE 105TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-6338
Mailing Address - Country:US
Mailing Address - Phone:503-740-5443
Mailing Address - Fax:866-535-1121
Practice Address - Street 1:8305 SE MONTEREY AVE
Practice Address - Street 2:SUITE #220-J
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-7725
Practice Address - Country:US
Practice Address - Phone:503-740-5443
Practice Address - Fax:866-535-1121
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13580225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist