Provider Demographics
NPI:1740522184
Name:SMALLS, GWENDOLYN CELESTE (MASTERS DEGREE)
Entity type:Individual
Prefix:MISS
First Name:GWENDOLYN
Middle Name:CELESTE
Last Name:SMALLS
Suffix:
Gender:F
Credentials:MASTERS DEGREE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 ST. JAMES PLACE #18B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205
Mailing Address - Country:US
Mailing Address - Phone:718-857-6543
Mailing Address - Fax:
Practice Address - Street 1:211 THROOP AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206
Practice Address - Country:US
Practice Address - Phone:718-443-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY746631971174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist