MEDICARE: JAMES EDMOND SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NONE	OTHER		NONE

General Provider Information

NPI Number	:	1659853729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES EDMOND SMITH

Provider Business Mailing Address
First Line	:	12718 N MACARTHUR BLVD APT K
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73142-2909
Country	:	US
Telephone Number	:	405-388-9464
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 N BROADWAY ST STE 100
Second Line	:
City	:	MOORE
State	:	OK
Zip	:	73160-5135
Country	:	US
Telephone Number	:	405-990-0816
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2018
Last Update Date	:	09/05/2018

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Directions to “ JAMES EDMOND SMITH ” Practice Location

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