Provider Demographics
NPI:1992914360
Name:SMALL, MICHAEL J (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:SMALL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:LONG LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12847-0130
Mailing Address - Country:US
Mailing Address - Phone:518-624-3346
Mailing Address - Fax:518-624-5557
Practice Address - Street 1:49 FAWN WAY
Practice Address - Street 2:
Practice Address - City:LONG LAKE
Practice Address - State:NY
Practice Address - Zip Code:12847-0130
Practice Address - Country:US
Practice Address - Phone:518-624-3346
Practice Address - Fax:518-624-5557
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013837103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB8932Medicare ID - Type Unspecified