Provider Demographics
NPI:1649988841
Name:SMITH, CHARLENE MARIE
Entity type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARLENE
Other - Middle Name:M
Other - Last Name:LOOSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2816 NW 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-8203
Mailing Address - Country:US
Mailing Address - Phone:949-572-0598
Mailing Address - Fax:
Practice Address - Street 1:2816 NW 37TH AVE
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-8203
Practice Address - Country:US
Practice Address - Phone:949-572-0598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-22-2106101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty