Provider Demographics
NPI:1003914367
Name:SMITH, LAUREL DIANE
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:DIANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11520 S 102ND EAST AVE
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-3007
Mailing Address - Country:US
Mailing Address - Phone:918-369-9985
Mailing Address - Fax:
Practice Address - Street 1:3015 E SKELLY DR
Practice Address - Street 2:SUITE 390
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6317
Practice Address - Country:US
Practice Address - Phone:918-665-0208
Practice Address - Fax:918-665-0216
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor