Provider Demographics
NPI:1558597732
Name:SMITH, VICTORIA I (DPT, LMT)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:I
Last Name:SMITH
Suffix:
Gender:F
Credentials:DPT, LMT
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT, LMT
Mailing Address - Street 1:11900 SW GREENBURG RD
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6453
Mailing Address - Country:US
Mailing Address - Phone:503-620-5556
Mailing Address - Fax:503-624-0118
Practice Address - Street 1:11900 SW GREENBURG RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6453
Practice Address - Country:US
Practice Address - Phone:503-620-5556
Practice Address - Fax:503-624-0118
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6967225100000X
OR15851225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500661639Medicaid
WA1558597732Medicaid
WAG8915153Medicare PIN
WA1558597732Medicaid