Provider Demographics
NPI:1205487139
Name:SMITH, STACEY C
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:C
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 1:4166 LINDELL BLVD STE 1B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2923
Mailing Address - Country:US
Mailing Address - Phone:314-484-7758
Mailing Address - Fax:
Practice Address - Street 1:4166 LINDELL BLVD STE 1B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2923
Practice Address - Country:US
Practice Address - Phone:314-484-7758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1073099404Medicaid