1104847227 NPI number — ROBERTA M SMALLS M.S.W.

Table of content: ROBERTA M SMALLS M.S.W. (NPI 1104847227)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104847227 NPI number — ROBERTA M SMALLS M.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMALLS
Provider First Name:
ROBERTA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S.W.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104847227
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22 WHITE HERON LK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST STROUDSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18302-8936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-620-6911
Provider Business Mailing Address Fax Number:
714-333-1817

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
523 SARAH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STROUDSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18360-2118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-620-6911
Provider Business Practice Location Address Fax Number:
714-333-1817
Provider Enumeration Date:
07/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  CW013133 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0018508420001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000924701 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 168715 . This is a "MEDICARE PTAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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