Provider Demographics
NPI:1194044214
Name:SMITH, ROBERTA DAYLE (BHRS)
Entity Type:Individual
Prefix:MR
First Name:ROBERTA
Middle Name:DAYLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15598 N 493 RD
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-1095
Mailing Address - Country:US
Mailing Address - Phone:918-207-6687
Mailing Address - Fax:
Practice Address - Street 1:2024 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-2758
Practice Address - Country:US
Practice Address - Phone:918-682-9292
Practice Address - Fax:918-682-0054
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator