Provider Demographics
NPI:1245612779
Name:SMITH, STACY G (MS, LMHC, LPC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:G
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, LMHC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 GODWIN AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:MIDLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07432-1927
Mailing Address - Country:US
Mailing Address - Phone:516-232-7775
Mailing Address - Fax:
Practice Address - Street 1:24 GODWIN AVE STE 210
Practice Address - Street 2:
Practice Address - City:MIDLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07432-1927
Practice Address - Country:US
Practice Address - Phone:516-232-7775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-21
Last Update Date:2018-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006573101YM0800X
NJ37PC00562000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health