MEDICARE: KELLEN SMITH

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1184925406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEN SMITH

Provider Business Mailing Address
First Line	:	8813 NE 12TH ST
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-7113
Country	:	US
Telephone Number	:	405-301-6521
Fax Number	:

Provider Business Practice Location Address
First Line	:	312 NE 28TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73105-2804
Country	:	US
Telephone Number	:	405-231-3150
Fax Number	:

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

Provider Enumeration Date	:	11/03/2010
Last Update Date	:	11/03/2010

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Directions to “ KELLEN SMITH ” Practice Location

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