Healthcare Provider Details

I. General information

NPI: 1629494091
Provider Name (Legal Business Name): CHARLOTTE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2014
Last Update Date: 03/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 W 17TH PL
TULSA OK
74119-4654
US

IV. Provider business mailing address

1870 S BOULDER AVE
TULSA OK
74119-5234
US

V. Phone/Fax

Practice location:
  • Phone: 918-585-1213
  • Fax: 918-585-9543
Mailing address:
  • Phone: 918-585-1213
  • Fax: 918-585-1263

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: