MEDICARE: STEPHANIE RAE SMITH CLC

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	101Y00000X	Counselor	ALPP-42079	WI

General Provider Information

NPI Number	:	1487160644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE RAE SMITH CLC

Provider Business Mailing Address
First Line	:	5126 MARTHA DR
Second Line	:
City	:	WEST BEND
State	:	WI
Zip	:	53095-8794
Country	:	US
Telephone Number	:	262-501-1359
Fax Number	:

Provider Business Practice Location Address
First Line	:	5126 MARTHA DR
Second Line	:
City	:	WEST BEND
State	:	WI
Zip	:	53095-8794
Country	:	US
Telephone Number	:	262-501-1359
Fax Number	:

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

Provider Enumeration Date	:	12/22/2017
Last Update Date	:	06/11/2019

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