Healthcare Provider Details

I. General information

NPI: 1043659428
Provider Name (Legal Business Name): BRENDON MICHAEL SMITH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2013
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 9TH AVE BOX 359612
SEATTLE WA
98104-2420
US

IV. Provider business mailing address

7841 STROUD AVE N
SEATTLE WA
98103-4922
US

V. Phone/Fax

Practice location:
  • Phone: 206-744-5862
  • Fax:
Mailing address:
  • Phone: 410-804-6511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: