MEDICARE: MELISSA MARIE SMITH CSWA, QMHP-R

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	A12708	OR

General Provider Information

NPI Number	:	1679241376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA MARIE SMITH CSWA, QMHP-R

Provider Business Mailing Address
First Line	:	1037 NOBLE AVE
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-3130
Country	:	US
Telephone Number	:	541-294-6593
Fax Number	:

Provider Business Practice Location Address
First Line	:	833 ANDERSON AVE STE 6
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-4641
Country	:	US
Telephone Number	:	541-286-6238
Fax Number	:

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

Provider Enumeration Date	:	08/30/2021
Last Update Date	:	08/30/2021

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