Healthcare Provider Details

I. General information

NPI: 1780235341
Provider Name (Legal Business Name): STEPHANIE MARIE SMITH LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 01/01/2026
Certification Date: 01/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 MESA GRANDE PL SE
ALBUQUERQUE NM
87108-2709
US

IV. Provider business mailing address

4210 MESA GRANDE PL SE
ALBUQUERQUE NM
87108-2709
US

V. Phone/Fax

Practice location:
  • Phone: 520-288-1079
  • Fax:
Mailing address:
  • Phone: 520-288-1079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701013645
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCTB-2022-0151
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: