Provider Demographics
NPI:1952685893
Name:SMITH, TAMMIE (MCP)
Entity Type:Individual
Prefix:
First Name:TAMMIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 SOUTH LAIRD STREET
Mailing Address - Street 2:
Mailing Address - City:MOORELAND
Mailing Address - State:OK
Mailing Address - Zip Code:73852
Mailing Address - Country:US
Mailing Address - Phone:580-571-1272
Mailing Address - Fax:580-994-2739
Practice Address - Street 1:1601 WILKIE RD
Practice Address - Street 2:
Practice Address - City:MOORELAND
Practice Address - State:OK
Practice Address - Zip Code:73852-8921
Practice Address - Country:US
Practice Address - Phone:580-994-5649
Practice Address - Fax:580-994-2739
Is Sole Proprietor?:No
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK839101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK839OtherOKLAHOMA BOARD OF LICENSED ALCOHOL AND DRUG CONSELOR