Provider Demographics
NPI:1255472049
Name:SMITH, LARA STEPHANIE (MS)
Entity Type:Individual
Prefix:MS
First Name:LARA
Middle Name:STEPHANIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621A MIDTOWN PL
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-6348
Mailing Address - Country:US
Mailing Address - Phone:405-340-9191
Mailing Address - Fax:405-340-9185
Practice Address - Street 1:2801 S BRYANT AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-6137
Practice Address - Country:US
Practice Address - Phone:405-340-9191
Practice Address - Fax:405-340-9185
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK314231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200067420AMedicaid