Provider Demographics
NPI:1790885515
Name:SMITH, MARY LOUISE (CPM, LDM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CPM, LDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7679 SW BAYBERRY DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-5504
Mailing Address - Country:US
Mailing Address - Phone:503-848-6883
Mailing Address - Fax:
Practice Address - Street 1:7679 SW BAYBERRY DR
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-5504
Practice Address - Country:US
Practice Address - Phone:503-848-6883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDEM-LD-250740176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDEM-LM-250740OtherMIDWIFERY LICENSE #
OR140041Medicaid
OR97100006OtherNARM CERTIFICATION/ CPM