Provider Demographics
NPI:1689315863
Name:SMALL, DAMIEN
Entity Type:Individual
Prefix:
First Name:DAMIEN
Middle Name:
Last Name:SMALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6121 WESTVIEW WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-1238
Mailing Address - Country:US
Mailing Address - Phone:916-607-2150
Mailing Address - Fax:
Practice Address - Street 1:3331 POWER INN RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-3889
Practice Address - Country:US
Practice Address - Phone:916-662-1539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA141363106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist