Provider Demographics
NPI:1942209895
Name:SMITH, BRENDA L (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 PENDLETON ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504-2947
Mailing Address - Country:US
Mailing Address - Phone:254-742-1524
Mailing Address - Fax:254-742-0789
Practice Address - Street 1:601 PENDLETON ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-2947
Practice Address - Country:US
Practice Address - Phone:254-742-1524
Practice Address - Fax:254-742-0789
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24041104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87327QOtherBCBS
TX162921405Medicaid
TX8B2261Medicare ID - Type Unspecified