Healthcare Provider Details

I. General information

NPI: 1740704907
Provider Name (Legal Business Name): REVEN C SMALLS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 07/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321A INTERSTATE PKWY
AUGUSTA GA
30909-5626
US

IV. Provider business mailing address

1321A INTERSTATE PKWY
AUGUSTA GA
30909-5626
US

V. Phone/Fax

Practice location:
  • Phone: 706-738-7246
  • Fax: 706-738-7248
Mailing address:
  • Phone: 706-738-7246
  • Fax: 706-738-7248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC006029
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: