Provider Demographics
NPI:1356767297
Name:SMART, STACEY C (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:C
Last Name:SMART
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:C
Other - Last Name:HARLUKOWICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OTR/L
Mailing Address - Street 1:355 CARRIE ST
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-2152
Mailing Address - Country:US
Mailing Address - Phone:231-690-3829
Mailing Address - Fax:
Practice Address - Street 1:1289 OLIVER ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4450
Practice Address - Country:US
Practice Address - Phone:910-483-8331
Practice Address - Fax:910-483-8335
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-17
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12478225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty