Provider Demographics
NPI:1548469448
Name:SMITH, LARRY EUGENE SR (CADC,ICADC)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:EUGENE
Last Name:SMITH
Suffix:SR
Gender:M
Credentials:CADC,ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 451585
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74345-1585
Mailing Address - Country:US
Mailing Address - Phone:918-787-7769
Mailing Address - Fax:918-787-7761
Practice Address - Street 1:32208 S. 620 RD
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344
Practice Address - Country:US
Practice Address - Phone:918-787-7769
Practice Address - Fax:918-787-7761
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK46, 13162101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK46,13162OtherCADC, ICADC