Provider Demographics
NPI:1619406139
Name:SMALLWOOD, KELLY ELIZABETH
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:SMALLWOOD
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 1:16013 LONE OAK DR
Mailing Address - Street 2:
Mailing Address - City:CATLETTSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41129-9291
Mailing Address - Country:US
Mailing Address - Phone:740-463-9192
Mailing Address - Fax:
Practice Address - Street 1:16013 LONE OAK DR
Practice Address - Street 2:
Practice Address - City:CATLETTSBURG
Practice Address - State:KY
Practice Address - Zip Code:41129-9291
Practice Address - Country:US
Practice Address - Phone:740-463-9192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency