Provider Demographics
NPI:1386426252
Name:SMITH, MONIQUE B (CADC-R)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:B
Last Name:SMITH
Suffix:
Gender:F
Credentials:CADC-R
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:B
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1160 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4143
Mailing Address - Country:US
Mailing Address - Phone:503-391-9762
Mailing Address - Fax:503-315-2019
Practice Address - Street 1:1160 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4143
Practice Address - Country:US
Practice Address - Phone:503-391-9762
Practice Address - Fax:503-315-2019
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-23-3143101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)