Provider Demographics
NPI:1548873136
Name:SMALL, MICHELLE JOY (BS)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JOY
Last Name:SMALL
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 2ND ST SW
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1482
Mailing Address - Country:US
Mailing Address - Phone:218-631-1714
Mailing Address - Fax:218-631-4228
Practice Address - Street 1:11 2ND ST SW
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1482
Practice Address - Country:US
Practice Address - Phone:218-631-1714
Practice Address - Fax:218-631-4228
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305793101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)