Provider Demographics
NPI:1982053492
Name:SMALL, KELLY M
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:SMALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 GUTHRIE RD STE 150
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-5078
Mailing Address - Country:US
Mailing Address - Phone:972-226-9585
Mailing Address - Fax:972-226-9580
Practice Address - Street 1:2306 GUTHRIE RD STE 150
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-5078
Practice Address - Country:US
Practice Address - Phone:972-226-9585
Practice Address - Fax:972-226-9580
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXATP4377247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other