Provider Demographics
NPI:1467547257
Name:SMITH, MAURICE BRADLEY (PHD,LP)
Entity Type:Individual
Prefix:DR
First Name:MAURICE
Middle Name:BRADLEY
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 COUNTY ROAD B2 W STE 270
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2785
Mailing Address - Country:US
Mailing Address - Phone:651-481-0664
Mailing Address - Fax:651-846-5877
Practice Address - Street 1:1935 COUNTY ROAD B2 W STE 270
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-2785
Practice Address - Country:US
Practice Address - Phone:651-481-0664
Practice Address - Fax:651-846-5877
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0783103TC0700X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP21325OtherHEALTH PARTNERS INSURANCE
MN27F90SMOtherBLUE CROSS/BLUE SHIELD
MN6150656OtherMEDICA/UNITED BEH. HEALTH
MN680016304OtherRAIL ROAD MEDICARE
MN092353200Medicaid