=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487627444
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUDITH A. SMITH, PSY.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2006
-----------------------------------------------------
Last Update Date | 03/26/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1732 SE ASH ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97214-1526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-239-7201
-----------------------------------------------------
Fax | 503-774-4589
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1732 SE ASH ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97214-1526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-239-7201
-----------------------------------------------------
Fax | 503-774-4589
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JUDITH A SMITH
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 503-239-7201
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 0945
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------