MEDICARE: MR. BRIAN O. SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	004076	NY

General Provider Information

NPI Number	:	1588998777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN O. SMITH

Provider Business Mailing Address
First Line	:	563 E 52ND ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11203-5311
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	563 E 52ND ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11203-5311
Country	:	US
Telephone Number	:	212-361-9334
Fax Number	:	718-495-1487

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2009
Last Update Date	:	09/22/2009

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