Provider Demographics
NPI:1154483006
Name:SMALL, PETER COBBOLD (LCSW)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:COBBOLD
Last Name:SMALL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 PIERCE ST APT 1003
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1003
Mailing Address - Country:US
Mailing Address - Phone:510-528-1590
Mailing Address - Fax:
Practice Address - Street 1:146 RAINIER AVE RM 5
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-1846
Practice Address - Country:US
Practice Address - Phone:707-553-5493
Practice Address - Fax:707-553-5719
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 215471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical