Provider Demographics
NPI:1841413598
Name:SMALL, RAYMOND (PHD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:
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 1:25047 MAPLERIDGE LANE
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN CHARTER TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48134
Mailing Address - Country:US
Mailing Address - Phone:313-415-9247
Mailing Address - Fax:
Practice Address - Street 1:7310 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3165
Practice Address - Country:US
Practice Address - Phone:313-896-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012596103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical