Provider Demographics
NPI:1609950104
Name:SMALL, DONNA JEAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:JEAN
Last Name:SMALL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 E MISSOURI AVE
Mailing Address - Street 2:#11
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-5061
Mailing Address - Country:US
Mailing Address - Phone:505-532-0843
Mailing Address - Fax:
Practice Address - Street 1:2801 E MISSOURI AVE
Practice Address - Street 2:#11
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5061
Practice Address - Country:US
Practice Address - Phone:505-532-0843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2024-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0871103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00NM00JL19OtherBCBS
NMNM100524Medicaid