Provider Demographics
NPI:1225541626
Name:SMITH, BRIAN KEITH (MSW)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:SMITH
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 MARIA LN
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-1135
Mailing Address - Country:US
Mailing Address - Phone:662-423-3332
Mailing Address - Fax:662-423-3331
Practice Address - Street 1:1213 MARIA LN
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-1135
Practice Address - Country:US
Practice Address - Phone:662-423-3332
Practice Address - Fax:662-423-3331
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-08
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist