Provider Demographics
NPI:1225113426
Name:SMITH, BRIAN EUGENE (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:EUGENE
Last Name:SMITH
Suffix:
Gender:M
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 CROYDON DR
Mailing Address - Street 2:
Mailing Address - City:SPRING CREEK
Mailing Address - State:NV
Mailing Address - Zip Code:89815-5919
Mailing Address - Country:US
Mailing Address - Phone:775-397-5215
Mailing Address - Fax:
Practice Address - Street 1:1020 RUBY VISTA DR
Practice Address - Street 2:SUITE 102
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-2879
Practice Address - Country:US
Practice Address - Phone:775-753-1214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2015-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-249235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV003404085Medicaid