Healthcare Provider Details

I. General information

NPI: 1730626144
Provider Name (Legal Business Name): LEAH SMART GORDON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2017
Last Update Date: 06/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 SW MACADAM AVE STE 580
PORTLAND OR
97239-3837
US

IV. Provider business mailing address

5200 SW MACADAM AVE STE 580
PORTLAND OR
97239-3837
US

V. Phone/Fax

Practice location:
  • Phone: 503-231-7854
  • Fax: 503-231-8153
Mailing address:
  • Phone: 503-231-7854
  • Fax: 503-231-8153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW14018
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL7245
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: