Healthcare Provider Details

I. General information

NPI: 1255257093
Provider Name (Legal Business Name): MS. LANETTA EVONNE SMALL-WHITTLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. LANETTA EVONNE SMALL

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 19120
FRESNO CA
93790-0120
US

IV. Provider business mailing address

PO BOX 19120
FRESNO CA
93790-0120
US

V. Phone/Fax

Practice location:
  • Phone: 350-229-3782
  • Fax:
Mailing address:
  • Phone: 350-229-3782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number240140895
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: