Provider Demographics
NPI:1710641139
Name:SMALL, EDAHN M
Entity Type:Individual
Prefix:
First Name:EDAHN
Middle Name:M
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 1:18663 VENTURA BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4161
Mailing Address - Country:US
Mailing Address - Phone:818-963-9319
Mailing Address - Fax:818-657-7440
Practice Address - Street 1:18663 VENTURA BLVD STE 300
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-4161
Practice Address - Country:US
Practice Address - Phone:818-963-9319
Practice Address - Fax:818-657-7440
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist