Provider Demographics
NPI:1104321991
Name:SMITH, BRACKEN (PPS)
Entity type:Individual
Prefix:
First Name:BRACKEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 VAN NESS AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-2002
Mailing Address - Country:US
Mailing Address - Phone:559-265-3000
Mailing Address - Fax:
Practice Address - Street 1:55190 POINT RD
Practice Address - Street 2:
Practice Address - City:BIG CREEK
Practice Address - State:CA
Practice Address - Zip Code:93605
Practice Address - Country:US
Practice Address - Phone:559-893-3314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2025-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220116511103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool