Provider Demographics
NPI:1962831842
Name:SMITH, AMBER ELISE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:ELISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9224 S ELWOOD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-2364
Mailing Address - Country:US
Mailing Address - Phone:918-409-0157
Mailing Address - Fax:
Practice Address - Street 1:9224 S ELWOOD AVE STE A
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-2364
Practice Address - Country:US
Practice Address - Phone:918-409-0157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK080117633235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist