Provider Demographics
NPI:1891945176
Name:SMALL, ELIZABETH R (LCSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:R
Last Name:SMALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 PARK ST
Mailing Address - Street 2:SUITE 35
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5093
Mailing Address - Country:US
Mailing Address - Phone:207-992-9454
Mailing Address - Fax:
Practice Address - Street 1:157 PARK ST
Practice Address - Street 2:SUITE 35
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5093
Practice Address - Country:US
Practice Address - Phone:207-992-9454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-24
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC115941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical