Provider Demographics
NPI:1255434668
Name:SMITH, ANNE-MARIE (PHD)
Entity type:Individual
Prefix:
First Name:ANNE-MARIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19365 SW 65TH AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9196
Mailing Address - Country:US
Mailing Address - Phone:503-936-6544
Mailing Address - Fax:503-691-0462
Practice Address - Street 1:19365 SW 65TH AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9196
Practice Address - Country:US
Practice Address - Phone:503-936-6544
Practice Address - Fax:503-691-0462
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1604103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
121219Medicare ID - Type Unspecified