Healthcare Provider Details

I. General information

NPI: 1255722500
Provider Name (Legal Business Name): STACI SMITH LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACI SHAW LISW-S

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 LEXINGTON AVE
MANSFIELD OH
44907-1906
US

IV. Provider business mailing address

78 MAYFAIR RD
MANSFIELD OH
44904-9781
US

V. Phone/Fax

Practice location:
  • Phone: 419-774-4010
  • Fax: 417-774-4014
Mailing address:
  • Phone: 260-668-6404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1500936-SUPV
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberS.1201024
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: