Provider Demographics
NPI:1295254373
Name:SMITH, BRANDEN M (LISW, LICDC)
Entity type:Individual
Prefix:
First Name:BRANDEN
Middle Name:M
Last Name:SMITH
Suffix:
Gender:M
Credentials:LISW, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27511 HOLIDAY LN STE 211
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5397
Mailing Address - Country:US
Mailing Address - Phone:419-450-0892
Mailing Address - Fax:
Practice Address - Street 1:27511 HOLIDAY LN STE 211
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5397
Practice Address - Country:US
Practice Address - Phone:419-450-0892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.162028101YA0400X
OHI.22037431041C0700X
OHCDCA163104101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical