Provider Demographics
NPI:1265170989
Name:SMITH, STACEY ANN SPENCER (LMHC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN SPENCER
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5071 E STELLAR WAY
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-8324
Mailing Address - Country:US
Mailing Address - Phone:360-620-4578
Mailing Address - Fax:
Practice Address - Street 1:5071 E STELLAR WAY
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-8324
Practice Address - Country:US
Practice Address - Phone:360-620-4578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00010149101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA00010149OtherSTATE PROVIDER LICENSURE