Provider Demographics
NPI:1932676558
Name:SMALLWOOD, THEIA
Entity Type:Individual
Prefix:
First Name:THEIA
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 1:590 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-2522
Mailing Address - Country:US
Mailing Address - Phone:973-596-3835
Mailing Address - Fax:973-596-3834
Practice Address - Street 1:108 ALDEN ST
Practice Address - Street 2:
Practice Address - City:CRANFORD
Practice Address - State:NJ
Practice Address - Zip Code:07016-2191
Practice Address - Country:US
Practice Address - Phone:908-497-3968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC057906001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical