Provider Demographics
NPI:1497825822
Name:SMITH, TOMMIE J (MS, LPC)
Entity Type:Individual
Prefix:
First Name:TOMMIE
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 S. SEMINOLE ST.
Mailing Address - Street 2:
Mailing Address - City:WEWOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74884
Mailing Address - Country:US
Mailing Address - Phone:405-257-3102
Mailing Address - Fax:
Practice Address - Street 1:RR 1, BOX 35D
Practice Address - Street 2:
Practice Address - City:BOLEY
Practice Address - State:OK
Practice Address - Zip Code:74829
Practice Address - Country:US
Practice Address - Phone:918-667-3367
Practice Address - Fax:918-667-3387
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK#4003101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100685660AMedicaid
OK100685660DMedicaid