Provider Demographics
NPI:1821761891
Name:SMALLS, LATRICE (RBT)
Entity Type:Individual
Prefix:
First Name:LATRICE
Middle Name:
Last Name:SMALLS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 ASHLEY PHOSPHATE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-6405
Mailing Address - Country:US
Mailing Address - Phone:843-813-1538
Mailing Address - Fax:
Practice Address - Street 1:2810 ASHLEY PHOSPHATE RD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-6405
Practice Address - Country:US
Practice Address - Phone:843-813-1538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRBT-17-34789106S00000X
SC1-23-69970103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician