Healthcare Provider Details

I. General information

NPI: 1083057566
Provider Name (Legal Business Name): TARA A SMITH ED.S, LPC, NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2013
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 SE 4TH ST STE C
MOORE OK
73160-6831
US

IV. Provider business mailing address

624 SW 159TH TER
OKLAHOMA CITY OK
73170-7626
US

V. Phone/Fax

Practice location:
  • Phone: 405-653-8012
  • Fax: 877-715-9937
Mailing address:
  • Phone: 405-653-7269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC07270
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number12-49 AE-PL
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: