MEDICARE: CARLA K SMITH RN, LPC-CAND.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	102202	OK
2	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1164720736	OTHER	OK	DDS

General Provider Information

NPI Number	:	1164720736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLA K SMITH RN, LPC-CAND.

Provider Business Mailing Address
First Line	:	3004 KAEYLEE LN
Second Line	:
City	:	DEL CITY
State	:	OK
Zip	:	73115-2500
Country	:	US
Telephone Number	:	405-512-1987
Fax Number	:

Provider Business Practice Location Address
First Line	:	5528 E RENO AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73117-8418
Country	:	US
Telephone Number	:	405-512-1987
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2011
Last Update Date	:	09/14/2021

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