Provider Demographics
NPI:1124631882
Name:SMITH, BROOKELYNN MAE FREED (LCSW, MSW, BSW)
Entity type:Individual
Prefix:
First Name:BROOKELYNN
Middle Name:MAE FREED
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW, MSW, BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-4502
Mailing Address - Country:US
Mailing Address - Phone:417-621-0373
Mailing Address - Fax:
Practice Address - Street 1:712 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-4502
Practice Address - Country:US
Practice Address - Phone:417-621-0373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020022699104100000X, 1041C0700X
MO20220388121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2020022699OtherMASTER OF SOCIAL WORK LICENSE
MO2022038812OtherCLINICAL SOCIAL WORK LICENSE