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General NPI Number Information
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NPI Number | 1275006215
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Entity Type | Individual
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Provider Name | CAMERON LEE SMALL MS, LPCC
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Gender | Male
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Dates
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Enumeration Date | 01/02/2019
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Last Update Date | 06/18/2020
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Provider Practice Location Address
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Address Line | 9156 VINCENT AVE S
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City | BLOOMINGTON
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State | MN
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Zip | 55431
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Country | US
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Telephone | 608-338-5707
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Fax |
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Provider Business Mailing Address
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Address Line | 9156 VINCENT AVE S
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City | BLOOMINGTON
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State | MN
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Zip | 55431
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Country | US
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Telephone | 608-338-5707
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | CC02017
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License Number State | MN
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