Provider Demographics
NPI:1124584370
Name:SMITH, STACEY
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-1988
Mailing Address - Country:US
Mailing Address - Phone:814-460-5236
Mailing Address - Fax:
Practice Address - Street 1:445 E DUBLIN GRANVILLE RD
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-3192
Practice Address - Country:US
Practice Address - Phone:814-460-5236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA29553196OtherDRIVERS LICENSE
PA29553196OtherDRIVERS LICENSE