Healthcare Provider Details

I. General information

NPI: 1558912113
Provider Name (Legal Business Name): CHARLES T SMALLS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 PEACHTREE ST NE STE 1200
ATLANTA GA
30309-7673
US

IV. Provider business mailing address

8833 CHURCHILL PL
JONESBORO GA
30238-4559
US

V. Phone/Fax

Practice location:
  • Phone: 646-841-3962
  • Fax:
Mailing address:
  • Phone: 404-464-6924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: