Provider Demographics
NPI:1336779602
Name:SMITH, STACIE JUNE MARIE
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:JUNE MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:JUNE MARIE
Other - Last Name:SEXSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3046 N KENMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-9094
Mailing Address - Country:US
Mailing Address - Phone:331-457-1325
Mailing Address - Fax:
Practice Address - Street 1:3046 N KENMORE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-9094
Practice Address - Country:US
Practice Address - Phone:331-457-1325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist