Provider Demographics
NPI:1861836587
Name:SMALLS, ROBERT LEE JR
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LEE
Last Name:SMALLS
Suffix:JR
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:PO BOX 470874
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-9174
Mailing Address - Country:US
Mailing Address - Phone:562-481-9216
Mailing Address - Fax:
Practice Address - Street 1:550 SOUTH VERMONT AVENUE
Practice Address - Street 2:JUVENILE JUSTICE TRANSITION AFTERCARE SERVICES DIVISION
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020
Practice Address - Country:US
Practice Address - Phone:213-738-4875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 68295106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist