Provider Demographics
NPI:1689676413
Name:SMALL, KENNETH GREGORY (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:GREGORY
Last Name:SMALL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-6515
Mailing Address - Country:US
Mailing Address - Phone:717-795-8588
Mailing Address - Fax:717-795-0541
Practice Address - Street 1:410 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17055-6515
Practice Address - Country:US
Practice Address - Phone:717-795-8588
Practice Address - Fax:717-795-0541
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-004858-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1458769Medicaid
PAR07351Medicare UPIN
PA1458769Medicaid