Provider Demographics
NPI:1679577050
Name:SMALLWOOD, JUSTIN RYAN (PT)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:RYAN
Last Name:SMALLWOOD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2431 S LOOP 289
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-1519
Mailing Address - Country:US
Mailing Address - Phone:806-771-8008
Mailing Address - Fax:806-771-8009
Practice Address - Street 1:1506 S SUNSET AVE
Practice Address - Street 2:
Practice Address - City:LITTLEFIELD
Practice Address - State:TX
Practice Address - Zip Code:79339-4899
Practice Address - Country:US
Practice Address - Phone:806-385-3746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPT1113686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX220047902Medicaid
TX220047901Medicaid
TXP00304755OtherMEDICARE RAILROAD
TX8T2619OtherBLUE CROSS BLUE SHIELD
TX138047103OtherFIRSTCARE
TX220047902Medicaid