Healthcare Provider Details

I. General information

NPI: 1003329905
Provider Name (Legal Business Name): DIANE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 WAITE ST
NORTH BEND OR
97459-1229
US

IV. Provider business mailing address

1890 WAITE ST
NORTH BEND OR
97459-1229
US

V. Phone/Fax

Practice location:
  • Phone: 541-756-6232
  • Fax: 541-756-6234
Mailing address:
  • Phone: 541-435-7000
  • Fax: 541-756-6234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC7279
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLCPC-8350
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: