Provider Demographics
NPI:1215731039
Name:SMITH, MACKENZIE L (PT, DPT, OCS)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:L
Last Name:SMITH
Suffix:
Gender:
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 W 130TH ST S
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-4429
Mailing Address - Country:US
Mailing Address - Phone:417-669-7373
Mailing Address - Fax:
Practice Address - Street 1:9001 S 101ST EAST AVE STE 170
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5799
Practice Address - Country:US
Practice Address - Phone:918-294-4060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6553225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist