MEDICARE: ELLEN KATHERINE SMITH LMT

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	173C00000X	Reflexologist	20920	OR
2	173C00000X	Reflexologist	MT121462	TX
3	225700000X	Massage Therapist	20920	OR
4	225700000X	Massage Therapist	MT121462	TX
5	226300000X	Kinesiotherapist	202920	OR
6	226300000X	Kinesiotherapist	MT121462	TX

General Provider Information

NPI Number	:	1932593688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN KATHERINE SMITH LMT

Provider Business Mailing Address
First Line	:	10225 SE RAYMOND ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97266-3635
Country	:	US
Telephone Number	:	971-266-1322
Fax Number	:

Provider Business Practice Location Address
First Line	:	10225 SE RAYMOND ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97266-3635
Country	:	US
Telephone Number	:	971-266-1322
Fax Number	:

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

Provider Enumeration Date	:	03/20/2015
Last Update Date	:	03/20/2015

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