Provider Demographics
NPI:1235627654
Name:SMITH, BRANDY S
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:S
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 1:500 SALUKI BLVD APT 1022C
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-8236
Mailing Address - Country:US
Mailing Address - Phone:217-663-5868
Mailing Address - Fax:
Practice Address - Street 1:136 PREMIER LN
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62902-4101
Practice Address - Country:US
Practice Address - Phone:715-577-8764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst