Provider Demographics
NPI:1558912113
Name:SMALLS, CHARLES T JR
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:T
Last Name:SMALLS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8833 CHURCHILL PL
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-4559
Mailing Address - Country:US
Mailing Address - Phone:404-464-6924
Mailing Address - Fax:
Practice Address - Street 1:1170 PEACHTREE ST NE STE 1200
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-7673
Practice Address - Country:US
Practice Address - Phone:646-841-3962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 103K00000X
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician