Provider Demographics
NPI:1053757948
Name:SMITH, TINA I (PSS)
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:I
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3211 AUTUMN CHASE WAY NE APT 104
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1561
Mailing Address - Country:US
Mailing Address - Phone:971-239-9675
Mailing Address - Fax:
Practice Address - Street 1:3211 AUTUMN CHASE WAY NE APT 104
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1561
Practice Address - Country:US
Practice Address - Phone:971-239-9675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-17
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR172V00000X
174400000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORO5329Medicaid