Provider Demographics
NPI:1487341152
Name:SMALL, MICHAEL II
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SMALL
Suffix:II
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 1:8654 THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-5193
Mailing Address - Country:US
Mailing Address - Phone:470-936-1704
Mailing Address - Fax:
Practice Address - Street 1:225 CEDAR HILL ST STE 200
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-5900
Practice Address - Country:US
Practice Address - Phone:470-936-1704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician