Provider Demographics
NPI:1205378858
Name:SMITH-MOORE, LILYAN CHARLOTTE RUSSEL (MED)
Entity type:Individual
Prefix:
First Name:LILYAN
Middle Name:CHARLOTTE RUSSEL
Last Name:SMITH-MOORE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9152
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-9152
Mailing Address - Country:US
Mailing Address - Phone:971-373-4497
Mailing Address - Fax:
Practice Address - Street 1:101 SW MADISON ST.
Practice Address - Street 2:UNIT 9152
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-3264
Practice Address - Country:US
Practice Address - Phone:971-373-4497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-14
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4955101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500725324Medicaid