Provider Demographics
NPI:1770658999
Name:SMITH, STEPHANIE ANNE (MA LPC)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 VILLAGE SQUARE DR STE G700
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-4286
Mailing Address - Country:US
Mailing Address - Phone:832-524-3617
Mailing Address - Fax:832-201-9738
Practice Address - Street 1:14011 PARK DR STE 220
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77377-6289
Practice Address - Country:US
Practice Address - Phone:832-524-3617
Practice Address - Fax:832-201-9738
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
TX14430101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172497301Medicaid
TX027618003Medicaid