Provider Demographics
NPI:1497094767
Name:SMITH, KAYLAN ROSE (LPC)
Entity type:Individual
Prefix:MRS
First Name:KAYLAN
Middle Name:ROSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:KAYLAN
Other - Middle Name:ROSE
Other - Last Name:CARPENTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:2507 MAIN AVE N
Mailing Address - Street 2:SUITE B
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-9297
Mailing Address - Country:US
Mailing Address - Phone:503-457-3445
Mailing Address - Fax:503-842-0001
Practice Address - Street 1:2507 MAIN AVE N
Practice Address - Street 2:SUITE B
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-9297
Practice Address - Country:US
Practice Address - Phone:503-457-3445
Practice Address - Fax:503-842-0001
Is Sole Proprietor?:No
Enumeration Date:2013-02-06
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORC3715101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR197749Medicaid