MEDICARE: GARETH ROBERT SMITH LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LW60159863	WA

General Provider Information

NPI Number	:	1457811887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARETH ROBERT SMITH LICSW

Provider Business Mailing Address
First Line	:	1601 E 4TH PLAIN BLVD
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98661-3713
Country	:	US
Telephone Number	:	503-753-1844
Fax Number	:

Provider Business Practice Location Address
First Line	:	14825 SW FARMINGTON RD
Second Line	:
City	:	BEAVERTON
State	:	OR
Zip	:	97007-2724
Country	:	US
Telephone Number	:	503-753-1844
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2019
Last Update Date	:	03/21/2019

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