Provider Demographics
NPI:1598954703
Name:SMALLWOOD, KELLY MICHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELLE
Last Name:SMALLWOOD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HIGHWAY 51 N
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2349
Mailing Address - Country:US
Mailing Address - Phone:601-833-7317
Mailing Address - Fax:601-835-0995
Practice Address - Street 1:300 HIGHWAY 51 N
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2349
Practice Address - Country:US
Practice Address - Phone:601-833-7317
Practice Address - Fax:601-835-0995
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA3648225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant