Healthcare Provider Details

I. General information

NPI: 1982904322
Provider Name (Legal Business Name): KRISTIN E SMITH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 W MAIN ST
PURCELL OK
73080-4220
US

IV. Provider business mailing address

112 W MAIN ST
PURCELL OK
73080-4220
US

V. Phone/Fax

Practice location:
  • Phone: 405-527-1785
  • Fax: 405-527-1084
Mailing address:
  • Phone: 405-527-1785
  • Fax: 405-527-1084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3958
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: