Healthcare Provider Details

I. General information

NPI: 1366159451
Provider Name (Legal Business Name): BRYAN DOREKO PAUL SMITH QP, ITFS, MHFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LOGGER CT STE E102
RALEIGH NC
27609-8510
US

IV. Provider business mailing address

2924 TRASSACKS DR
RALEIGH NC
27610-5497
US

V. Phone/Fax

Practice location:
  • Phone: 919-900-7200
  • Fax: 919-900-7201
Mailing address:
  • Phone: 919-900-7200
  • Fax: 919-900-7201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225CA2400X
TaxonomyAssistive Technology Practitioner Rehabilitation Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: