Healthcare Provider Details

I. General information

NPI: 1508778382
Provider Name (Legal Business Name): BRANTLEY SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14131 MIDWAY RD STE 112
ADDISON TX
75001-3605
US

IV. Provider business mailing address

4309 COUNTRY LN
GRAPEVINE TX
76051-6715
US

V. Phone/Fax

Practice location:
  • Phone: 817-807-8352
  • Fax:
Mailing address:
  • Phone: 817-807-8352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number97955
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: