Provider Demographics
NPI:1659759645
Name:SMALLWOOD, CRAIG WARNE (MS, LBS)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:WARNE
Last Name:SMALLWOOD
Suffix:
Gender:M
Credentials:MS, LBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 MAHANTONGO ST
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3010
Mailing Address - Country:US
Mailing Address - Phone:570-573-9178
Mailing Address - Fax:
Practice Address - Street 1:221 MAHANTONGO ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3010
Practice Address - Country:US
Practice Address - Phone:570-573-9178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2022-11-29
Deactivation Date:2019-09-12
Deactivation Code:
Reactivation Date:2022-11-29
Provider Licenses
StateLicense IDTaxonomies
PABH000182103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst