Provider Demographics
NPI:1255962049
Name:SMALLER, MARK DAVID (LCSW, PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:SMALLER
Suffix:
Gender:M
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 93
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:MI
Mailing Address - Zip Code:49406-0093
Mailing Address - Country:US
Mailing Address - Phone:312-731-9251
Mailing Address - Fax:
Practice Address - Street 1:45 BLUE STAR HWY
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:MI
Practice Address - Zip Code:49406-5139
Practice Address - Country:US
Practice Address - Phone:312-731-9251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010897921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical