Provider Demographics
NPI:1821060104
Name:SMITH, BRENDA (HSPP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W TIPTON ST
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-2363
Mailing Address - Country:US
Mailing Address - Phone:812-522-2349
Mailing Address - Fax:812-522-0524
Practice Address - Street 1:411 W TIPTON ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2363
Practice Address - Country:US
Practice Address - Phone:812-522-2349
Practice Address - Fax:812-522-0524
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040831A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000322621OtherANTHEM PIN
IN200260340AMedicaid
IN200260340AMedicaid
IN941010AAMedicare PIN