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General NPI Number Information
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NPI Number | 1487168142
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Entity Type | Individual
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Provider Name | BRENDA G SMITH LMT
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Gender | Female
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Dates
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Enumeration Date | 11/16/2017
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Last Update Date | 11/16/2017
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Provider Practice Location Address
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Address Line | 1545 E IRON EAGLE DR STE 103
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City | EAGLE
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State | ID
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Zip | 83616-7079
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Country | US
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Telephone | 208-649-4405
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Fax |
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Provider Business Mailing Address
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Address Line | 10633 N SAGECREST PL
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City | BOISE
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State | ID
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Zip | 83714-9562
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Country | US
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Telephone | 404-441-1146
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MASG-2220
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License Number State | ID
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