Basic Information
| Provider Information | |||||||||
| NPI: | 1205973864 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CADC I | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1710 | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977560516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415049577 | ||||||||
| FaxNumber: | 5415042361 | ||||||||
| Practice Location | |||||||||
| Address1: | 676 NE NEGUS WAY | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977568527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415049577 | ||||||||
| FaxNumber: | 5415042361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 02-11-74 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 210831 | 05 | OR | MEDICAID |