Provider Demographics
NPI:1306112503
Name:SMITH, PAUL
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:PAUL
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BS, MA
Mailing Address - Street 1:PO BOX 707001
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74170-7001
Mailing Address - Country:US
Mailing Address - Phone:888-247-0125
Mailing Address - Fax:918-502-8210
Practice Address - Street 1:6655 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3326
Practice Address - Country:US
Practice Address - Phone:918-491-3700
Practice Address - Fax:918-481-4063
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
OK7170101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner