Provider Demographics
NPI:1174679062
Name:OWEN, STACEY SMOOT (PHD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:SMOOT
Last Name:OWEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5398 THOMASTON RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31220-8110
Mailing Address - Country:US
Mailing Address - Phone:478-476-8868
Mailing Address - Fax:478-476-8161
Practice Address - Street 1:5398 THOMASTON RD
Practice Address - Street 2:SUITE B
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31220-8110
Practice Address - Country:US
Practice Address - Phone:478-476-8868
Practice Address - Fax:478-476-8161
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003006103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical