Provider Demographics
NPI:1780044073
Name:SMITH, BRANDON G (LADC/MH)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:G
Last Name:SMITH
Suffix:
Gender:M
Credentials:LADC/MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-6508
Mailing Address - Country:US
Mailing Address - Phone:405-332-3001
Mailing Address - Fax:580-332-8774
Practice Address - Street 1:230 E 12TH ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-6508
Practice Address - Country:US
Practice Address - Phone:580-332-3001
Practice Address - Fax:580-332-8774
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1450101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator