Doctor Name: | DR. KENT DAVID SMALLWOOD |
NPI Number: | 1679767016 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | PH.D. |
License Number: | LP5358 |
Business Practice Address: | 15251 Pleasant Valley Rd # Co7 Center City, MN - 550129640 |
Business Phone Number: | 6512134169 |
Business Fax Number: | 6512134515 |
Mailing Address: | 15251 Pleasant Valley Rd # Co7, Po Box 11 CENTER CITY |
State: | MN |
Postal Code: | 550129640 |
Phone Number: | 6512134169 |
Fax Number: | 6512134515 |
NPI Enumeration Date: | 08/29/2007 |
NPI Last Update Date: | 10/16/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TC0700X |
License Number: | LP5358 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MN |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: |