Provider Demographics
NPI:1508699828
Name:SMITH, KAITLYN CHEYENNE
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:CHEYENNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32357 W HIGHWAY 66
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:OK
Mailing Address - Zip Code:74010-2638
Mailing Address - Country:US
Mailing Address - Phone:918-260-5460
Mailing Address - Fax:
Practice Address - Street 1:11982 S MULBERRY CT
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-2181
Practice Address - Country:US
Practice Address - Phone:918-201-1865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician