Provider Demographics
NPI:1760891832
Name:SMITH, ELIZABETH MAE (LCSW)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4228
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4228
Mailing Address - Country:US
Mailing Address - Phone:541-316-6026
Mailing Address - Fax:541-323-3866
Practice Address - Street 1:2065 NE TUCSON WAY APT 110
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-5182
Practice Address - Country:US
Practice Address - Phone:541-383-3005
Practice Address - Fax:541-383-1883
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL107721041C0700X, 1041C0700X
ORA54791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500700865Medicaid
OR1760891832Medicaid