Provider Demographics
NPI:1154450617
Name:SMITH, BRENT IRVIN (DHSC, ATC, LAT)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:IRVIN
Last Name:SMITH
Suffix:
Gender:M
Credentials:DHSC, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146D RECREATION HALL
Mailing Address - Street 2:THE PENNSYLVANIA STATE UNIVERSITY
Mailing Address - City:UNIVERSITY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:16802-6501
Mailing Address - Country:US
Mailing Address - Phone:814-865-8816
Mailing Address - Fax:814-865-7936
Practice Address - Street 1:146D RECREATION HALL
Practice Address - Street 2:THE PENNSYLVANIA STATE UNIVERSITY
Practice Address - City:UNIVERSITY PARK
Practice Address - State:PA
Practice Address - Zip Code:16802-6501
Practice Address - Country:US
Practice Address - Phone:814-865-8816
Practice Address - Fax:814-865-7936
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0035272255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer