Provider Demographics
NPI:1891161139
Name:SMALL, KEVIN WILSON (PTA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:WILSON
Last Name:SMALL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 RIDGEMONT DR
Mailing Address - Street 2:
Mailing Address - City:LONDONDERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03053-3103
Mailing Address - Country:US
Mailing Address - Phone:603-851-1163
Mailing Address - Fax:
Practice Address - Street 1:175 BLUEBERRY LN
Practice Address - Street 2:
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246-2918
Practice Address - Country:US
Practice Address - Phone:603-524-3340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1210225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant