Provider Demographics
NPI:1457526964
Name:SMOCKVILLE PROFESSIONAL SERVICES, INC
Entity Type:Organization
Organization Name:SMOCKVILLE PROFESSIONAL SERVICES, INC
Other - Org Name:SMOCKVILLE COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:RANDOM
Authorized Official - Last Name:HEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-625-2768
Mailing Address - Street 1:22344 SW MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-9416
Mailing Address - Country:US
Mailing Address - Phone:503-625-2768
Mailing Address - Fax:503-625-3768
Practice Address - Street 1:22344 SW MAIN ST
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9416
Practice Address - Country:US
Practice Address - Phone:503-625-2768
Practice Address - Fax:503-625-3768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty