Healthcare Provider Details

I. General information

NPI: 1164185252
Provider Name (Legal Business Name): ELIZABETH DAFFER SMITH PHD, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2021
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 STONEHILL DR
GLADSTONE OR
97027-1673
US

IV. Provider business mailing address

555 STONEHILL DR
GLADSTONE OR
97027-1673
US

V. Phone/Fax

Practice location:
  • Phone: 971-303-8464
  • Fax:
Mailing address:
  • Phone: 971-303-8464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL6293
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: