Provider Demographics
NPI:1972819688
Name:SMALL, LYNETTE (PSYD)
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2331
Mailing Address - Country:US
Mailing Address - Phone:602-257-9339
Mailing Address - Fax:
Practice Address - Street 1:2632 E THOMAS RD
Practice Address - Street 2:SUITE 100-101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-8220
Practice Address - Country:US
Practice Address - Phone:602-957-2507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3780103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist