Provider Demographics
NPI:1952414070
Name:SMITH, BRIAN A (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 W 1ST ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3056
Mailing Address - Country:US
Mailing Address - Phone:815-285-3073
Mailing Address - Fax:815-285-3103
Practice Address - Street 1:119 W 1ST ST
Practice Address - Street 2:SUITE 110
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3056
Practice Address - Country:US
Practice Address - Phone:815-285-3073
Practice Address - Fax:815-285-3103
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical