Provider Demographics
NPI:1053669796
Name:SMALLWOOD, LORETTA (LMT)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:SMALLWOOD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 TOWN BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-1326
Mailing Address - Country:US
Mailing Address - Phone:606-599-9425
Mailing Address - Fax:
Practice Address - Street 1:411 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-1212
Practice Address - Country:US
Practice Address - Phone:606-391-3584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0683225700000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist