Provider Demographics
NPI:1386187342
Name:SMITH, STACY (MSW, LISW)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSW, LISW
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:FOSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LSW
Mailing Address - Street 1:4726 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-6929
Mailing Address - Country:US
Mailing Address - Phone:440-992-8552
Mailing Address - Fax:440-992-6631
Practice Address - Street 1:4726 MAIN AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-6929
Practice Address - Country:US
Practice Address - Phone:440-992-8552
Practice Address - Fax:440-992-6631
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.18013331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical