Provider Demographics
NPI:1366159451
Name:SMITH, BRYAN DOREKO PAUL (QP, ITFS, MHFA)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:DOREKO PAUL
Last Name:SMITH
Suffix:
Gender:M
Credentials:QP, ITFS, MHFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 TRASSACKS DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-5497
Mailing Address - Country:US
Mailing Address - Phone:919-900-7200
Mailing Address - Fax:919-900-7201
Practice Address - Street 1:1100 LOGGER CT STE E102
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-8510
Practice Address - Country:US
Practice Address - Phone:919-900-7200
Practice Address - Fax:919-900-7201
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No174H00000XOther Service ProvidersHealth Educator
No225CA2400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorAssistive Technology Practitioner
No374700000XNursing Service Related ProvidersTechnician
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide