1497094767 NPI number — MRS. KAYLAN ROSE SMITH LPC

Table of content: MRS. KAYLAN ROSE SMITH LPC (NPI 1497094767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497094767 NPI number — MRS. KAYLAN ROSE SMITH LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
KAYLAN
Provider Middle Name:
ROSE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARPENTER
Provider Other First Name:
KAYLAN
Provider Other Middle Name:
ROSE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1497094767
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2507 MAIN AVE N
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
TILLAMOOK
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97141-9297
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-457-3445
Provider Business Mailing Address Fax Number:
503-842-0001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2507 MAIN AVE N
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
TILLAMOOK
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97141-9297
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-457-3445
Provider Business Practice Location Address Fax Number:
503-842-0001
Provider Enumeration Date:
02/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: C3715 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 197749 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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