MEDICARE: DR. STACEY SMOOT OWEN PH.D.

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	103TC0700X	Clinical Psychologist	PSY003006	GA

General Provider Information

NPI Number	:	1174679062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACEY SMOOT OWEN PH.D.

Provider Business Mailing Address
First Line	:	5398 THOMASTON RD
Second Line	:	SUITE B
City	:	MACON
State	:	GA
Zip	:	31220-8110
Country	:	US
Telephone Number	:	478-476-8868
Fax Number	:	478-476-8161

Provider Business Practice Location Address
First Line	:	5398 THOMASTON RD
Second Line	:	SUITE B
City	:	MACON
State	:	GA
Zip	:	31220-8110
Country	:	US
Telephone Number	:	478-476-8868
Fax Number	:	478-476-8161

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

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	07/08/2007

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