Provider Demographics
NPI:1629796214
Name:SMALLBONE, MARY THERESE JOY
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:THERESE JOY
Last Name:SMALLBONE
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 1:103 CONTINENTAL PL
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-1041
Mailing Address - Country:US
Mailing Address - Phone:615-481-8405
Mailing Address - Fax:
Practice Address - Street 1:103 CONTINENTAL PL
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-1041
Practice Address - Country:US
Practice Address - Phone:615-481-8405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2028101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty