Provider Demographics
NPI:1477802320
Name:SMALL, DILLON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DILLON
Middle Name:
Last Name:SMALL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4760 SOUTH SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230
Mailing Address - Country:US
Mailing Address - Phone:310-390-6612
Mailing Address - Fax:
Practice Address - Street 1:2348 SIJAN DR STE 2A13
Practice Address - Street 2:
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840-8203
Practice Address - Country:US
Practice Address - Phone:317-362-4878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043068A103TC0700X
COPSY..0005552103TC0700X
COPSY.0005552103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical