Provider Demographics
NPI:1306834015
Name:SMITH, BRYAN E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:E
Last Name:SMITH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5411 PLAZA DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-1666
Mailing Address - Country:US
Mailing Address - Phone:903-255-0171
Mailing Address - Fax:903-255-0172
Practice Address - Street 1:5411 PLAZA DR
Practice Address - Street 2:SUITE E
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-1666
Practice Address - Country:US
Practice Address - Phone:903-255-0171
Practice Address - Fax:903-255-0172
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-07
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-5159103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR139710719Medicaid
TX0307068-01Medicaid
TX0307068-01Medicaid
TX00608EMedicare ID - Type Unspecified