Healthcare Provider Details

I. General information

NPI: 1891301990
Provider Name (Legal Business Name): MARY EDSON SMITH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 NW CIVIC DR STE 310
GRESHAM OR
97030-3774
US

IV. Provider business mailing address

1224 NE 53RD AVE
PORTLAND OR
97213-2858
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-8832
  • Fax:
Mailing address:
  • Phone: 971-716-4822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL10327
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: