Healthcare Provider Details

I. General information

NPI: 1821761891
Provider Name (Legal Business Name): LATRICE SMALLS RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 ASHLEY PHOSPHATE RD
NORTH CHARLESTON SC
29418-6405
US

IV. Provider business mailing address

2810 ASHLEY PHOSPHATE RD
NORTH CHARLESTON SC
29418-6405
US

V. Phone/Fax

Practice location:
  • Phone: 843-813-1538
  • Fax:
Mailing address:
  • Phone: 843-813-1538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-69970
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-34789
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: