Provider Demographics
NPI:1730474404
Name:SMITH, STACEY DARNELL
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:DARNELL
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 1:6015 YAUPON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77469-1681
Mailing Address - Country:US
Mailing Address - Phone:210-823-8606
Mailing Address - Fax:
Practice Address - Street 1:2100 WEST LOOP S
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-3515
Practice Address - Country:US
Practice Address - Phone:713-965-9998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1168913225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist