Provider Demographics
NPI:1376954149
Name:SMALL, MOLLY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9478 WHITE TAIL RUN
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:OH
Mailing Address - Zip Code:44001-9458
Mailing Address - Country:US
Mailing Address - Phone:419-706-0033
Mailing Address - Fax:
Practice Address - Street 1:2 WILDCAT DR
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:OH
Practice Address - Zip Code:44851-9262
Practice Address - Country:US
Practice Address - Phone:419-557-6797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-15
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP. 11135235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist