Provider Demographics
NPI:1811355175
Name:SMALLS, LAKELL
Entity type:Individual
Prefix:
First Name:LAKELL
Middle Name:
Last Name:SMALLS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LAKELL
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 CRAIG ST
Mailing Address - Street 2:
Mailing Address - City:EUTAWVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29048-9582
Mailing Address - Country:US
Mailing Address - Phone:843-695-7234
Mailing Address - Fax:
Practice Address - Street 1:110 NNPTC CIR
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-6314
Practice Address - Country:US
Practice Address - Phone:843-794-6456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596480Medicaid