Healthcare Provider Details

I. General information

NPI: 1679939920
Provider Name (Legal Business Name): ALYCIA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2015
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 NE ROBERTS AVE STE 200
GRESHAM OR
97030-7484
US

IV. Provider business mailing address

4233 SE 182ND AVE # 212
GRESHAM OR
97030-5082
US

V. Phone/Fax

Practice location:
  • Phone: 971-220-2496
  • Fax:
Mailing address:
  • Phone: 971-220-2496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG60615744
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW60824262
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL7466
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: