Provider Demographics
NPI:1184334054
Name:SMALLWOOD, AUDRA (MS, LBS)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:SMALLWOOD
Suffix:
Gender:F
Credentials:MS, LBS
Other - Prefix:
Other - First Name:AUDRA
Other - Middle Name:
Other - Last Name:BECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LBS
Mailing Address - Street 1:385 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOHRSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19541-8841
Mailing Address - Country:US
Mailing Address - Phone:484-272-2604
Mailing Address - Fax:
Practice Address - Street 1:1103 ROCKY RD STE 202
Practice Address - Street 2:
Practice Address - City:WEST LAWN
Practice Address - State:PA
Practice Address - Zip Code:19609-1166
Practice Address - Country:US
Practice Address - Phone:484-272-2604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-01
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
PAPC019144101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health