Healthcare Provider Details

I. General information

NPI: 1922555853
Provider Name (Legal Business Name): MS. SHANASI LEE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 08/15/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N EAST AVE APT 7B
TAHLEQUAH OK
74464-2419
US

IV. Provider business mailing address

118 SBK 410 ROAD
STIGLER OK
74462
US

V. Phone/Fax

Practice location:
  • Phone: 918-730-3637
  • Fax:
Mailing address:
  • Phone: 918-316-5925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number07432
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: