Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist |
NPI | 1376874339 |
---|---|
Provider Name | Miss Ebony Michelle Smith |
First Address | Moore, OK 73160-0900 |
Second Address | Moore, OK 73160-0900 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/01/2010 |
Last Update Date | 14/01/2010 |