Provider Demographics
NPI:1558475012
Name:SMITH, BRENT RODERICK (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:RODERICK
Last Name:SMITH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6692 SPRING ARBOR RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-9322
Mailing Address - Country:US
Mailing Address - Phone:517-750-3869
Mailing Address - Fax:517-750-3673
Practice Address - Street 1:6692 SPRING ARBOR RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201
Practice Address - Country:US
Practice Address - Phone:517-750-3869
Practice Address - Fax:517-750-3869
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008782103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680C845330OtherBLUE CROSS BLUE SHIELD MI