MEDICARE: MR. BRANDON SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1861125486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRANDON SMITH

Provider Business Mailing Address
First Line	:	7725 N 43RD AVE STE 711
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85051-5772
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7725 N 43RD AVE STE 711
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85051-5772
Country	:	US
Telephone Number	:	602-815-5128
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2022
Last Update Date	:	07/01/2022

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