=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245612779
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACY G. SMITH MS, LMHC, LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2015
-----------------------------------------------------
Last Update Date | 04/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24 GODWIN AVE STE 210
-----------------------------------------------------
City | MIDLAND PARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07432-1927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-232-7775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 GODWIN AVE STE 210
-----------------------------------------------------
City | MIDLAND PARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07432-1927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-232-7775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 006573
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 37PC00562000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------