MEDICARE: STACIE SMITHEE LCSW

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	1041C0700X	Clinical Social Worker	2005005745	MO

General Provider Information

NPI Number	:	1417012972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIE SMITHEE LCSW

Provider Business Mailing Address
First Line	:	5760 COUNTY ROAD 114
Second Line	:
City	:	FULTON
State	:	MO
Zip	:	65251-3827
Country	:	US
Telephone Number	:	573-642-5345
Fax Number	:	573-642-0981

Provider Business Practice Location Address
First Line	:	8548 JADE ROAD
Second Line	:
City	:	KINGDOM CITY
State	:	MO
Zip	:	65262
Country	:	US
Telephone Number	:	573-642-5345
Fax Number	:	573-642-5345

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

Provider Enumeration Date	:	12/26/2006
Last Update Date	:	07/09/2007

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