Provider Demographics
NPI:1093261182
Name:SMOCK, STACI LYNNE (LCSW)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:LYNNE
Last Name:SMOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 BOARDWALK DR UNIT 5A
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3093
Mailing Address - Country:US
Mailing Address - Phone:720-334-8891
Mailing Address - Fax:
Practice Address - Street 1:300 BOARDWALK DR UNIT 5A
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3093
Practice Address - Country:US
Practice Address - Phone:720-334-8891
Practice Address - Fax:970-223-2324
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-29
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099272921041C0700X
KS45781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical