Provider Demographics
NPI:1457463515
Name:SMITH, STEPHANIE (LIC PSYC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LIC PSYC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3375 US ROUTE 60
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2837
Mailing Address - Country:US
Mailing Address - Phone:304-525-7851
Mailing Address - Fax:304-525-1073
Practice Address - Street 1:3375 US ROUTE 60
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2837
Practice Address - Country:US
Practice Address - Phone:304-525-7851
Practice Address - Fax:304-525-1073
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV622103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical