Healthcare Provider Details

I. General information

NPI: 1659853729
Provider Name (Legal Business Name): JAMES EDMOND SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 09/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N BROADWAY ST STE 100
MOORE OK
73160-5135
US

IV. Provider business mailing address

12718 N MACARTHUR BLVD APT K
OKLAHOMA CITY OK
73142-2909
US

V. Phone/Fax

Practice location:
  • Phone: 405-990-0816
  • Fax:
Mailing address:
  • Phone: 405-388-9464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: