Healthcare Provider Details

I. General information

NPI: 1841582228
Provider Name (Legal Business Name): SYNTHIA M SMART LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23440 SE STARK ST
GRESHAM OR
97030-2961
US

IV. Provider business mailing address

4843 SE 64TH AVE
PORTLAND OR
97206-4639
US

V. Phone/Fax

Practice location:
  • Phone: 503-489-6245
  • Fax:
Mailing address:
  • Phone: 503-680-9710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number16865
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: