Provider Demographics
NPI:1922582188
Name:SMALL, KELCIE MARIE
Entity Type:Individual
Prefix:
First Name:KELCIE
Middle Name:MARIE
Last Name:SMALL
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 1:132 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBORO
Mailing Address - State:IN
Mailing Address - Zip Code:46167-9548
Mailing Address - Country:US
Mailing Address - Phone:317-363-5849
Mailing Address - Fax:
Practice Address - Street 1:6437 RUCKER RD STE D
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4868
Practice Address - Country:US
Practice Address - Phone:317-405-9016
Practice Address - Fax:800-654-4116
Is Sole Proprietor?:No
Enumeration Date:2018-09-23
Last Update Date:2022-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist