Provider Demographics
NPI:1912547944
Name:SMALLWOOD, KRISTI
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:
Last Name:SMALLWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:DIERKS
Mailing Address - State:AR
Mailing Address - Zip Code:71833-9421
Mailing Address - Country:US
Mailing Address - Phone:870-784-0884
Mailing Address - Fax:
Practice Address - Street 1:1820 CENTRAL AVE STE B
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-6898
Practice Address - Country:US
Practice Address - Phone:501-623-6000
Practice Address - Fax:501-623-6004
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR7121-M101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR251712795Medicaid