Provider Demographics
NPI:1174260806
Name:SMALL, SHAKINA (MS, NCC, LPC, LBC)
Entity type:Individual
Prefix:
First Name:SHAKINA
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:MS, NCC, LPC, LBC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3003
Mailing Address - Country:US
Mailing Address - Phone:215-895-5697
Mailing Address - Fax:
Practice Address - Street 1:12 N PRESTON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2211
Practice Address - Country:US
Practice Address - Phone:267-225-7638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-15
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
PAPC016304101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional