Healthcare Provider Details

I. General information

NPI: 1861063430
Provider Name (Legal Business Name): BRANDEN SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2021
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 3RD AVE SE STE 4
PERHAM MN
56573-1752
US

IV. Provider business mailing address

113 MINNESOTA AVE
DETROIT LAKES MN
56501-2420
US

V. Phone/Fax

Practice location:
  • Phone: 218-422-6131
  • Fax:
Mailing address:
  • Phone: 218-849-9810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4337
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: