Provider Demographics
NPI:1891186490
Name:SMITH, BRANDELYN BAGGETT (LPC)
Entity Type:Individual
Prefix:
First Name:BRANDELYN
Middle Name:BAGGETT
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 WARD ST E
Mailing Address - Street 2:PO BOX 2009
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-0301
Mailing Address - Country:US
Mailing Address - Phone:912-384-4357
Mailing Address - Fax:912-384-4356
Practice Address - Street 1:617 WARD ST E
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-0301
Practice Address - Country:US
Practice Address - Phone:912-384-4357
Practice Address - Fax:912-384-4356
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007508101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003155672AMedicaid
GA472699374OtherEIN