Provider Demographics
NPI:1417489501
Name:SMITH, BREANNE NICOLE (CP60896258)
Entity type:Individual
Prefix:MS
First Name:BREANNE
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CP60896258
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-1409
Mailing Address - Country:US
Mailing Address - Phone:509-895-1584
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 217
Practice Address - Street 2:
Practice Address - City:SELAH
Practice Address - State:WA
Practice Address - Zip Code:98942-0217
Practice Address - Country:US
Practice Address - Phone:509-457-0990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60896258101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)