Provider Demographics
NPI:1497445837
Name:SMALL, SHELLEY (CASE MANAGER)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 CHARLOTTE ST
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-3604
Mailing Address - Country:US
Mailing Address - Phone:216-319-9583
Mailing Address - Fax:
Practice Address - Street 1:50 CHARLOTTE ST
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-3604
Practice Address - Country:US
Practice Address - Phone:216-319-9583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2024-04-15
Deactivation Date:2024-03-28
Deactivation Code:
Reactivation Date:2024-04-11
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator