Provider Demographics
NPI:1710216353
Name:BLAKESLEE SMITH, ROBIN C (LMT)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:C
Last Name:BLAKESLEE SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10440 SW PAULINA DR
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8550
Mailing Address - Country:US
Mailing Address - Phone:503-267-4977
Mailing Address - Fax:
Practice Address - Street 1:12566 SW MAIN ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6129
Practice Address - Country:US
Practice Address - Phone:503-799-9543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-10
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10871174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist