Provider Demographics
NPI:1376044099
Name:SMALL, SAMANTHA MICHELLE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MICHELLE
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 1:200 QUINN DR STE 250
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15275-1055
Mailing Address - Country:US
Mailing Address - Phone:412-294-1267
Mailing Address - Fax:
Practice Address - Street 1:200 QUINN DR STE 250
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15275-1055
Practice Address - Country:US
Practice Address - Phone:412-294-1267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS019983103T00000X
UT10970604-2501103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty