Provider Demographics
NPI:1578318291
Name:SMALL ERNST, JULIET NATALIE AI
Entity Type:Individual
Prefix:
First Name:JULIET
Middle Name:NATALIE AI
Last Name:SMALL ERNST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8401
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94662-0401
Mailing Address - Country:US
Mailing Address - Phone:510-216-3988
Mailing Address - Fax:
Practice Address - Street 1:5299 COLLEGE AVE STE P
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-2816
Practice Address - Country:US
Practice Address - Phone:510-216-3988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA127880106H00000X
CA10166101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist