Provider Demographics
NPI:1083057566
Name:SMITH, TARA A (EDS, LPC, NCSP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:A
Last Name:SMITH
Suffix:
Gender:
Credentials:EDS, LPC, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 SW 159TH TER
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-7626
Mailing Address - Country:US
Mailing Address - Phone:405-653-7269
Mailing Address - Fax:
Practice Address - Street 1:501 SE 4TH ST STE C
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-6831
Practice Address - Country:US
Practice Address - Phone:405-653-8012
Practice Address - Fax:877-715-9937
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-15
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR12-49 AE-PL103T00000X
222Q00000X, 101YP2500X
OKLPC07270101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional