Healthcare Provider Details

I. General information

NPI: 1073242889
Provider Name (Legal Business Name): MICHAEL EUGENE SMALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 12/18/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 CARLISLE BLVD NE
ALBUQUERQUE NM
87110-1678
US

IV. Provider business mailing address

3150 CARLISLE BLVD NE
ALBUQUERQUE NM
87110-1678
US

V. Phone/Fax

Practice location:
  • Phone: 505-638-8178
  • Fax:
Mailing address:
  • Phone: 505-638-8178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2022-0902
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: