Provider Demographics
NPI:1932593688
Name:SMITH, ELLEN KATHERINE (LMT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:KATHERINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10225 SE RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-3635
Mailing Address - Country:US
Mailing Address - Phone:971-266-1322
Mailing Address - Fax:
Practice Address - Street 1:10225 SE RAYMOND ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-3635
Practice Address - Country:US
Practice Address - Phone:971-266-1322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20920173C00000X, 225700000X
TXMT121462173C00000X, 225700000X, 226300000X
OR202920226300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist
No226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist