Provider Demographics
NPI:1962033357
Name:SMALL, ALEXANDRIA ELISSA (LAC)
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:ELISSA
Last Name:SMALL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 RIDGEDALE AVE STE J
Mailing Address - Street 2:
Mailing Address - City:FLORHAM PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07932-1764
Mailing Address - Country:US
Mailing Address - Phone:973-515-1216
Mailing Address - Fax:973-515-3108
Practice Address - Street 1:171 RIDGEDALE AVE STE J
Practice Address - Street 2:
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-1764
Practice Address - Country:US
Practice Address - Phone:973-515-1216
Practice Address - Fax:973-515-3108
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2025-10-17
Deactivation Date:2025-09-09
Deactivation Code:
Reactivation Date:2025-10-17
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00912600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health