MEDICARE: STACI LYNNE SMOCK LCSW

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	1041C0700X	Clinical Social Worker	CSW.09927292	CO
2	1041C0700X	Clinical Social Worker	4578	KS

General Provider Information

NPI Number	:	1093261182
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACI LYNNE SMOCK LCSW

Provider Business Mailing Address
First Line	:	300 BOARDWALK DR UNIT 5A
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3093
Country	:	US
Telephone Number	:	720-334-8891
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 BOARDWALK DR UNIT 5A
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3093
Country	:	US
Telephone Number	:	720-334-8891
Fax Number	:	970-223-2324

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

Provider Enumeration Date	:	08/29/2016
Last Update Date	:	09/27/2022

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