Provider Demographics
NPI:1104434638
Name:SMITH, CLARENCE RUSSELL (MSW)
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:RUSSELL
Last Name:SMITH
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:MR
Other - First Name:CLARENCE
Other - Middle Name:R
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:1311 N LOTTIE AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-2051
Mailing Address - Country:US
Mailing Address - Phone:405-600-3074
Mailing Address - Fax:405-605-8120
Practice Address - Street 1:1311 N LOTTIE AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-2051
Practice Address - Country:US
Practice Address - Phone:405-600-3074
Practice Address - Fax:405-605-8120
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist