Provider Demographics
NPI:1578861175
Name:SMITH, COLLEEN ALICIA (LMT)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ALICIA
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 SW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2361
Mailing Address - Country:US
Mailing Address - Phone:503-544-8726
Mailing Address - Fax:
Practice Address - Street 1:430 SW 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2361
Practice Address - Country:US
Practice Address - Phone:503-544-8726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-05
Last Update Date:2011-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16502225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist