Provider Demographics
NPI:1689099384
Name:SMITH, DIANDRIA (BCBA)
Entity type:Individual
Prefix:
First Name:DIANDRIA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17613 CRANBROOK RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-6954
Mailing Address - Country:US
Mailing Address - Phone:405-519-3170
Mailing Address - Fax:
Practice Address - Street 1:4127 NW 122ND ST STE C
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8880
Practice Address - Country:US
Practice Address - Phone:405-455-6868
Practice Address - Fax:405-562-3444
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OK1-21-52366103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health