Provider Demographics
NPI:1619038007
Name:SMITH, STACEY MARIE (MPT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 MONTANA AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-1875
Mailing Address - Country:US
Mailing Address - Phone:310-458-0898
Mailing Address - Fax:
Practice Address - Street 1:1502 MONTANA AVE STE 207
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-1875
Practice Address - Country:US
Practice Address - Phone:310-458-0898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 22447225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT 224470OtherBLUE SHIELD
CAOPT 224470OtherBLUE SHIELD