Basic Information
| Provider Information | |||||||||
| NPI: | 1780884296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | SHANNY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9210 S 71ST EAST AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741335382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185241753 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7010 S YALE AVE STE 215 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741365743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184922554 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2007 | ||||||||
| LastUpdateDate: | 07/23/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.