Provider Demographics
NPI:1174545305
Name:SMALL, JONATHAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:SMALL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 FLEETS COVE RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-1517
Mailing Address - Country:US
Mailing Address - Phone:631-838-3932
Mailing Address - Fax:
Practice Address - Street 1:163 FLEETS COVE RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-1517
Practice Address - Country:US
Practice Address - Phone:631-838-3932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013618-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01922201Medicaid
NY01922201Medicaid