Provider Demographics
NPI:1366826737
Name:SMALL, SHAQUANA (MMHC, LMHC)
Entity Type:Individual
Prefix:
First Name:SHAQUANA
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:MMHC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 TOPLIFF STREET
Mailing Address - Street 2:1
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122
Mailing Address - Country:US
Mailing Address - Phone:617-548-9248
Mailing Address - Fax:
Practice Address - Street 1:56 TOPLIFF ST
Practice Address - Street 2:1
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-1018
Practice Address - Country:US
Practice Address - Phone:617-548-9248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health