Provider Demographics
NPI:1972846640
Name:SMITH, SANDRA CAGLE (CCC/SLP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:CAGLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 E LEE AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-4308
Mailing Address - Country:US
Mailing Address - Phone:918-224-2028
Mailing Address - Fax:918-224-0129
Practice Address - Street 1:511 E LEE AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4308
Practice Address - Country:US
Practice Address - Phone:918-224-2028
Practice Address - Fax:918-224-0129
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK951235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1447440896Medicaid