Healthcare Provider Details

I. General information

NPI: 1053669796
Provider Name (Legal Business Name): LORETTA SMALLWOOD L.M.T
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 RICHMOND RD
MANCHESTER KY
40962-1212
US

IV. Provider business mailing address

313 TOWN BRANCH RD
MANCHESTER KY
40962-1326
US

V. Phone/Fax

Practice location:
  • Phone: 606-391-3584
  • Fax:
Mailing address:
  • Phone: 606-599-9425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0683
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: