Healthcare Provider Details

I. General information

NPI: 1962116350
Provider Name (Legal Business Name): TEINESHA RYSHEK SMALLWOOD LCSW-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2023
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 ROANOKE AVE
ELIZABETH CITY NC
27909-5643
US

IV. Provider business mailing address

PO BOX 44
WINDSOR NC
27983-0044
US

V. Phone/Fax

Practice location:
  • Phone: 252-338-4370
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP018555
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: