Healthcare Provider Details

I. General information

NPI: 1972427631
Provider Name (Legal Business Name): ANNALIESE BROOKLYN SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 E 91ST ST STE 201
TULSA OK
74137-2862
US

IV. Provider business mailing address

1013 S DATE AVE
BROKEN ARROW OK
74012-5414
US

V. Phone/Fax

Practice location:
  • Phone: 918-730-9124
  • Fax:
Mailing address:
  • Phone: 918-730-9124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-2837192
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: