Healthcare Provider Details

I. General information

NPI: 1881351344
Provider Name (Legal Business Name): THERESA MARIE SMALLWOOD LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2021
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 4TH AVE STE 304
SAN DIEGO CA
92103-4294
US

IV. Provider business mailing address

2615 SWEETWATER SPRINGS BOULEVARD STE G PMB 1025
SPRING VALLEY CA
91978-1725
US

V. Phone/Fax

Practice location:
  • Phone: 858-481-8827
  • Fax: 858-244-0990
Mailing address:
  • Phone: 858-869-1096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10868
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: