Basic Information
Provider Information | |||||||||
NPI: | 1780069047 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRUBAKER | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | SMITH | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | SR. | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1500 N WILMOT RD STE A200 | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857124416 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5208738562 | ||||||||
FaxNumber: | 8888517021 | ||||||||
Practice Location | |||||||||
Address1: | 3295 W INA RD STE 125 | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857412195 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5202571168 | ||||||||
FaxNumber: | 5203064861 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2015 | ||||||||
LastUpdateDate: | 09/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW-2457 | AZ | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.