Provider Demographics
NPI:1851721799
Name:SMITH, LONNETTA
Entity Type:Individual
Prefix:
First Name:LONNETTA
Middle Name:
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 1:7901 NE 10TH ST STE A209
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-3689
Mailing Address - Country:US
Mailing Address - Phone:405-455-4646
Mailing Address - Fax:
Practice Address - Street 1:7901 NE 10TH ST STE A209
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-3689
Practice Address - Country:US
Practice Address - Phone:405-455-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst