MEDICARE: THERESA MARIE SMALLWOOD LPCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	10868	CA

General Provider Information

NPI Number	:	1881351344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA MARIE SMALLWOOD LPCC

Provider Business Mailing Address
First Line	:	2615 SWEETWATER SPRINGS BOULEVARD
Second Line	:	STE G PMB 1025
City	:	SPRING VALLEY
State	:	CA
Zip	:	91978-1725
Country	:	US
Telephone Number	:	858-869-1096
Fax Number	:

Provider Business Practice Location Address
First Line	:	3636 4TH AVE STE 304
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-4294
Country	:	US
Telephone Number	:	858-481-8827
Fax Number	:	858-244-0990

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2021
Last Update Date	:	06/15/2026

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