Provider Demographics
NPI:1538723671
Name:SMITH, BRYAN (CADC)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3203 PINE VALLEY WAY
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18302-6706
Mailing Address - Country:US
Mailing Address - Phone:551-404-7340
Mailing Address - Fax:
Practice Address - Street 1:3203 PINE VALLEY WAY
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18302-6706
Practice Address - Country:US
Practice Address - Phone:551-404-7340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37CA00155600101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty