Provider Demographics
NPI:1639440159
Name:SMITH, STACI
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:SMITH
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:PO BOX 13219
Mailing Address - Street 2:
Mailing Address - City:COYOTE
Mailing Address - State:CA
Mailing Address - Zip Code:95013-3219
Mailing Address - Country:US
Mailing Address - Phone:408-281-6555
Mailing Address - Fax:408-281-6580
Practice Address - Street 1:9500 MALECH ROAD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95138
Practice Address - Country:US
Practice Address - Phone:408-281-6555
Practice Address - Fax:408-281-6580
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker