Provider Demographics
NPI:1376285866
Name:SMALL, OLIVIA REGAN
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:REGAN
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 1:610 HERMITAGE PL
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30005-6767
Mailing Address - Country:US
Mailing Address - Phone:404-973-9903
Mailing Address - Fax:
Practice Address - Street 1:1 DUNWOODY PARK
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-7404
Practice Address - Country:US
Practice Address - Phone:470-702-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARBT-22-211130OtherRBT