Provider Demographics
NPI:1174631956
Name:SMALL, DONNA SUE (PLMHP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:SUE
Last Name:SMALL
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 YOUREE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3600
Mailing Address - Country:US
Mailing Address - Phone:318-742-3408
Mailing Address - Fax:402-826-5859
Practice Address - Street 1:1410 S GRAND ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-2012
Practice Address - Country:US
Practice Address - Phone:402-324-5441
Practice Address - Fax:402-324-5442
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE94080OtherBLUECROSS BLUESHIELD
NE470774254-26Medicaid