Provider Demographics
NPI:1831302884
Name:SMITH, STACEY J (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 3 BOX 408
Mailing Address - Street 2:
Mailing Address - City:MOUNDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26041-9529
Mailing Address - Country:US
Mailing Address - Phone:304-845-7852
Mailing Address - Fax:
Practice Address - Street 1:WHEELING HOSPITAL INC
Practice Address - Street 2:1 MEDICAL PARK
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003
Practice Address - Country:US
Practice Address - Phone:304-243-3770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0714235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV09106882OtherAMERICAN SPEECH