Provider Demographics
NPI:1588237408
Name:SMALLS, ELANGENIE
Entity Type:Individual
Prefix:
First Name:ELANGENIE
Middle Name:
Last Name:SMALLS
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 1:1099 PLAYGROUND RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-6465
Mailing Address - Country:US
Mailing Address - Phone:843-573-2111
Mailing Address - Fax:
Practice Address - Street 1:1099 PLAYGROUND RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-6465
Practice Address - Country:US
Practice Address - Phone:843-573-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty