Provider Demographics
NPI:1215182373
Name:SMALL, KATIE MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:MARIE
Last Name:SMALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 LUDLOW ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-1810
Mailing Address - Country:US
Mailing Address - Phone:207-774-0838
Mailing Address - Fax:
Practice Address - Street 1:500 FOREST AVE
Practice Address - Street 2:SUITE 9
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-1541
Practice Address - Country:US
Practice Address - Phone:207-838-6088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC117401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical