Provider Demographics
NPI:1780791590
Name:SMALLEY, MARK A (LCSW, LADC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:SMALLEY
Suffix:
Gender:M
Credentials:LCSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3712 E 11TH STREET
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74112
Mailing Address - Country:US
Mailing Address - Phone:918-622-1944
Mailing Address - Fax:918-834-4189
Practice Address - Street 1:3712 E 11TH STREET
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74112
Practice Address - Country:US
Practice Address - Phone:918-834-4194
Practice Address - Fax:918-834-4189
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical