Provider Demographics
NPI:1376874339
Name:SMITH, EBONY MICHELLE
Entity Type:Individual
Prefix:MISS
First Name:EBONY
Middle Name:MICHELLE
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 1:912 BLACK JACK LN
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-0900
Mailing Address - Country:US
Mailing Address - Phone:405-406-6010
Mailing Address - Fax:
Practice Address - Street 1:912 BLACK JACK LN
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-0900
Practice Address - Country:US
Practice Address - Phone:405-406-6010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-14
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation