Provider Demographics
NPI:1881969236
Name:SMALL, DAVID MICHAEL (PHD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:SMALL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 BAREFOOT BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-8505
Mailing Address - Country:US
Mailing Address - Phone:920-213-2754
Mailing Address - Fax:239-992-3053
Practice Address - Street 1:240 BAREFOOT BEACH BLVD
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-8505
Practice Address - Country:US
Practice Address - Phone:920-213-2754
Practice Address - Fax:239-992-3053
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1938-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist