Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003329905 |
---|---|
Provider Name | Diane Smith |
First Address | Ontario, OR 97914-3121 |
Second Address | Ontario, OR 97914-3121 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/11/2017 |
Last Update Date | 14/11/2017 |