Provider Demographics
NPI:1982128997
Name:SMITH, BRADY M
Entity type:Individual
Prefix:
First Name:BRADY
Middle Name:M
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BRIGHAM YOUNG UNIVERSITY
Mailing Address - Street 2:123 SAB
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84602
Mailing Address - Country:US
Mailing Address - Phone:801-422-1549
Mailing Address - Fax:
Practice Address - Street 1:BRIGHAM YOUNG UNIVERSITY
Practice Address - Street 2:123 SAB
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84602
Practice Address - Country:US
Practice Address - Phone:801-422-1549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9749511-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer