Provider Demographics
NPI:1417633215
Name:SMITH, MARIO KEENAN
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:KEENAN
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 1:4908 S SHERIDAN
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145
Mailing Address - Country:US
Mailing Address - Phone:918-984-9153
Mailing Address - Fax:
Practice Address - Street 1:4908 S SHERIDAN
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145
Practice Address - Country:US
Practice Address - Phone:918-984-9153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician