Provider Demographics
NPI:1962889709
Name:SMITH, BRANDY ROSE (MSW, LISW-S)
Entity type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:ROSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSW, LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 HARDWOODS DR
Mailing Address - Street 2:
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-7002
Mailing Address - Country:US
Mailing Address - Phone:740-255-1209
Mailing Address - Fax:
Practice Address - Street 1:700 BROOKSEDGE BLVD
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-2820
Practice Address - Country:US
Practice Address - Phone:740-255-1209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI13032831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0200375Medicaid