Healthcare Provider Details

I. General information

NPI: 1083735625
Provider Name (Legal Business Name): STEPHANIE R NESMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 08/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27811 PORTLAND AVE
BLANCHARD OK
73010
US

IV. Provider business mailing address

27811 PORTLAND AVE
BLANCHARD OK
73010-7150
US

V. Phone/Fax

Practice location:
  • Phone: 580-229-6274
  • Fax: 405-632-1976
Mailing address:
  • Phone: 580-229-6247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: