Provider Demographics
NPI:1679295661
Name:SMITH, BRENDA K
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:K
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 E NEW YORK ST
Mailing Address - Street 2:
Mailing Address - City:FORTVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46040-1072
Mailing Address - Country:US
Mailing Address - Phone:812-325-7599
Mailing Address - Fax:
Practice Address - Street 1:1200 E 42ND ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-2004
Practice Address - Country:US
Practice Address - Phone:317-232-0882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist