Provider Demographics
NPI:1861063430
Name:SMITH, BRANDEN
Entity type:Individual
Prefix:
First Name:BRANDEN
Middle Name:
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 1:113 MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-2420
Mailing Address - Country:US
Mailing Address - Phone:218-849-9810
Mailing Address - Fax:
Practice Address - Street 1:1041 HAWK ST
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-6958
Practice Address - Country:US
Practice Address - Phone:218-844-6853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
MN4337101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional