Provider Demographics
NPI:1295471480
Name:SMALL, KENYA M
Entity Type:Individual
Prefix:
First Name:KENYA
Middle Name:M
Last Name:SMALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 TOWBIN AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5928
Mailing Address - Country:US
Mailing Address - Phone:833-599-2560
Mailing Address - Fax:
Practice Address - Street 1:201 LACKAWANNA AVE STE 321
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503-1953
Practice Address - Country:US
Practice Address - Phone:833-599-2560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health