Provider Demographics
NPI:1114503596
Name:SMARTT-GIBSON, STACY B
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:B
Last Name:SMARTT-GIBSON
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 1:6356 GORAL CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4319
Mailing Address - Country:US
Mailing Address - Phone:301-503-9789
Mailing Address - Fax:
Practice Address - Street 1:2112 F ST NW
Practice Address - Street 2:STE 102
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037
Practice Address - Country:US
Practice Address - Phone:202-349-3209
Practice Address - Fax:202-822-9130
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1032487163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)