Provider Demographics
NPI:1396147310
Name:SMITH, BRENT WARREN (LP, PHD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:WARREN
Last Name:SMITH
Suffix:
Gender:M
Credentials:LP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 E LEAGUE CITY PKWY
Mailing Address - Street 2:STE 104 PMB 1050
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-3369
Mailing Address - Country:US
Mailing Address - Phone:409-209-7511
Mailing Address - Fax:
Practice Address - Street 1:2640 E LEAGUE CITY PKWY
Practice Address - Street 2:STE 104 PMB 1050
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-3369
Practice Address - Country:US
Practice Address - Phone:409-209-7511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-22
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37358103T00000X, 103T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program