Provider Demographics
NPI:1811583743
Name:SMITH, BRYAN KEITH
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:KEITH
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LILE CT STE 103
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6239
Mailing Address - Country:US
Mailing Address - Phone:501-400-7504
Mailing Address - Fax:
Practice Address - Street 1:1 LILE CT STE 103
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6239
Practice Address - Country:US
Practice Address - Phone:501-400-7504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health