Provider Demographics
NPI:1528397494
Name:SMITH, TONY LAVON JR
Entity Type:Individual
Prefix:MR
First Name:TONY
Middle Name:LAVON
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SW 173RD AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3995 MARCOLA ROAD
Practice Address - Street 2:THE CHILD CENTER
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477
Practice Address - Country:US
Practice Address - Phone:541-726-1465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health