Provider Demographics
NPI:1467563650
Name:SMALL, GLORIA (PHD)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 LONG HILL RD
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-1870
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26 LONG HILL ROAD
Practice Address - Street 2:
Practice Address - City:GUILPORD
Practice Address - State:CT
Practice Address - Zip Code:06437
Practice Address - Country:US
Practice Address - Phone:208-453-2932
Practice Address - Fax:203-453-9062
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001413103T00000X
CT000203106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
181674OtherOTHER
NH5128OtherOTHER
CT004140852Medicare ID - Type Unspecified
181674OtherOTHER