Healthcare Provider Details

I. General information

NPI: 1093254955
Provider Name (Legal Business Name): GROVER EUGENE SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3419 NE SANDY BLVD
PORTLAND OR
97232-1959
US

IV. Provider business mailing address

3419 NE SANDY BLVD
PORTLAND OR
97232-1959
US

V. Phone/Fax

Practice location:
  • Phone: 702-807-5522
  • Fax:
Mailing address:
  • Phone: 702-807-5522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: