Provider Demographics
NPI:1952674210
Name:SMITH, VICKIE LAVERNE (OTR/L)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:LAVERNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 DOBIE CT
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1481
Mailing Address - Country:US
Mailing Address - Phone:541-255-9927
Mailing Address - Fax:
Practice Address - Street 1:2510 NW EDENBOWER BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8899
Practice Address - Country:US
Practice Address - Phone:541-440-3052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1009487225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist