Provider Demographics
NPI:1871628636
Name:SMALL, LINDA D (PHD)
Entity type:Individual
Prefix:DR
First Name:LINDA
Middle Name:D
Last Name:SMALL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LAKE ST
Mailing Address - Street 2:# 23C
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1015
Mailing Address - Country:US
Mailing Address - Phone:630-968-4300
Mailing Address - Fax:630-968-4385
Practice Address - Street 1:1100 LAKE ST
Practice Address - Street 2:STE 275
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1039
Practice Address - Country:US
Practice Address - Phone:630-968-4300
Practice Address - Fax:630-968-4385
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-004196103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL983790Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER