Basic Information
| Provider Information | |||||||||
| NPI: | 1861769424 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | MARY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CADCII | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3580 MARSHALL AVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974021998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413432993 | ||||||||
| FaxNumber: | 5416844162 | ||||||||
| Practice Location | |||||||||
| Address1: | 3580 MARSHALL AVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974021998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413432996 | ||||||||
| FaxNumber: | 5416844162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2011 | ||||||||
| LastUpdateDate: | 01/31/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 03-03-64 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.