Provider Demographics
NPI:1447598230
Name:SMITH, BRENT ANDREW (DPT)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:ANDREW
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:PECOS
Mailing Address - State:TX
Mailing Address - Zip Code:79772-5721
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1640 N ZARAGOZA RD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-8004
Practice Address - Country:US
Practice Address - Phone:915-562-8525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118370225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist