Provider Demographics
NPI:1316116213
Name:TINA L. SMITH
Entity type:Organization
Organization Name:TINA L. SMITH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MED, CCC-SLP
Authorized Official - Phone:405-691-6567
Mailing Address - Street 1:10344 GREENBRIAR PKWY
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-7643
Mailing Address - Country:US
Mailing Address - Phone:405-691-6567
Mailing Address - Fax:405-392-2425
Practice Address - Street 1:10344 GREENBRIAR PKWY
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7643
Practice Address - Country:US
Practice Address - Phone:405-691-6567
Practice Address - Fax:405-392-2425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2821235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty