Provider Demographics
NPI:1124369814
Name:SMITH, STACY M (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 EVELYN RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-3048
Mailing Address - Country:US
Mailing Address - Phone:901-619-1645
Mailing Address - Fax:870-739-5123
Practice Address - Street 1:200 MANOR ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-1936
Practice Address - Country:US
Practice Address - Phone:870-739-5100
Practice Address - Fax:870-739-5123
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP1275235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist