Provider Demographics
NPI:1831972454
Name:SMITH, BROOKE (RBT)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 BAY BRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4467
Mailing Address - Country:US
Mailing Address - Phone:850-463-8810
Mailing Address - Fax:
Practice Address - Street 1:42 BAY BRIDGE DR
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4467
Practice Address - Country:US
Practice Address - Phone:850-463-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL10445842OtherDRIVERS LICENSE