Provider Demographics
NPI:1407236508
Name:SMITH, BRADLEY S (LISW-S)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:S
Last Name:SMITH
Suffix:
Gender:M
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 ANGILINE DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6573
Mailing Address - Country:US
Mailing Address - Phone:330-507-5867
Mailing Address - Fax:
Practice Address - Street 1:25 N CANFIELD NILES RD
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-2328
Practice Address - Country:US
Practice Address - Phone:330-797-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1200362-SUPV104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker