Provider Demographics
NPI:1477667046
Name:SMITH, JOHN BRADLEY (PCC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BRADLEY
Last Name:SMITH
Suffix:
Gender:M
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8970
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-0970
Mailing Address - Country:US
Mailing Address - Phone:419-782-4196
Mailing Address - Fax:
Practice Address - Street 1:6825 N STATE ROUTE 66
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-6730
Practice Address - Country:US
Practice Address - Phone:419-782-4196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0003984101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1366526782Medicaid