Provider Demographics
NPI:1043065428
Name:SMITH, HADEACHA A
Entity type:Individual
Prefix:MRS
First Name:HADEACHA
Middle Name:A
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 1:2621 E 88TH ST APT 437
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-1122
Mailing Address - Country:US
Mailing Address - Phone:918-805-3528
Mailing Address - Fax:
Practice Address - Street 1:2448 E 81ST ST STE 4460
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-4251
Practice Address - Country:US
Practice Address - Phone:918-600-2966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-19
Last Update Date:2024-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK319274171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator