Provider Demographics
NPI:1407296288
Name:ACT PSYCHOLOGICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:ACT PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SMALLWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:612-836-3886
Mailing Address - Street 1:1028 PIKE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-2427
Mailing Address - Country:US
Mailing Address - Phone:612-836-3886
Mailing Address - Fax:
Practice Address - Street 1:4601 EXCELSIOR BLVD STE 507A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4977
Practice Address - Country:US
Practice Address - Phone:612-836-3886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5358251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health