Provider Demographics
NPI:1487083226
Name:DR. KENNETH G. SMALL
Entity type:Organization
Organization Name:DR. KENNETH G. SMALL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:G
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:717-795-8588
Mailing Address - Street 1:410 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-6515
Mailing Address - Country:US
Mailing Address - Phone:717-795-8588
Mailing Address - Fax:717-795-0541
Practice Address - Street 1:410 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17055-6515
Practice Address - Country:US
Practice Address - Phone:717-795-8588
Practice Address - Fax:717-795-0541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS004858-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAR07351Medicare UPIN