=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619291713
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENNA R SMITH LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2010
-----------------------------------------------------
Last Update Date | 03/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 925 NW 19TH AVE SUITE C
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97209-1418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-810-2298
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 925 NW 19TH AVE SUITE C
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97209-1418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-810-2298
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 12891
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------