Healthcare Provider Details

I. General information

NPI: 1356872808
Provider Name (Legal Business Name): STACEY CHARLENE SMITH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2199 PHILLIPSBURG RD
DAMASCUS GA
39841-2009
US

IV. Provider business mailing address

2199 PHILLIPSBURG RD
DAMASCUS GA
39841-2009
US

V. Phone/Fax

Practice location:
  • Phone: 318-302-1053
  • Fax:
Mailing address:
  • Phone: 318-302-1053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11176
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW006018
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: