Provider Demographics
NPI:1124372669
Name:SMITH, KRISTINA LOUISE
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:LOUISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:LOUISE
Other - Last Name:BOONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:406 MAPLE ST STE 2
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-2657
Mailing Address - Country:US
Mailing Address - Phone:918-520-9863
Mailing Address - Fax:
Practice Address - Street 1:406 MAPLE ST STE 2
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-2657
Practice Address - Country:US
Practice Address - Phone:918-520-9863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
OK6050101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker