Provider Demographics
NPI:1417012451
Name:SMITH, BRENDA L (MSW)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 OXBOW RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-4926
Mailing Address - Country:US
Mailing Address - Phone:978-369-7745
Mailing Address - Fax:978-287-0238
Practice Address - Street 1:66 JUNCTION SQUARE DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-3049
Practice Address - Country:US
Practice Address - Phone:978-369-7745
Practice Address - Fax:978-287-0238
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1033001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP01066OtherBCBS OF MA