Provider Demographics
NPI:1265725741
Name:SMITH, KELLY R
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:R
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 1:34396 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:WHITESBORO
Mailing Address - State:OK
Mailing Address - Zip Code:74577-1019
Mailing Address - Country:US
Mailing Address - Phone:918-647-6823
Mailing Address - Fax:
Practice Address - Street 1:34396 RIVER RD
Practice Address - Street 2:
Practice Address - City:WHITESBORO
Practice Address - State:OK
Practice Address - Zip Code:74577-1019
Practice Address - Country:US
Practice Address - Phone:918-647-6823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor