Provider Demographics
NPI:1366040149
Name:SMITH, ALYSSA JOY
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:JOY
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 1:4211 N REDMOND AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-2809
Mailing Address - Country:US
Mailing Address - Phone:918-260-2024
Mailing Address - Fax:
Practice Address - Street 1:6612 NW 42ND ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-2764
Practice Address - Country:US
Practice Address - Phone:405-717-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional