Provider Demographics
NPI:1740476514
Name:SMITH, STACY ANN (LPC, NCC, MT-BC)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC, NCC, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4112 BLUE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-4652
Mailing Address - Country:US
Mailing Address - Phone:919-815-0688
Mailing Address - Fax:
Practice Address - Street 1:4525 DRAPER RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-5674
Practice Address - Country:US
Practice Address - Phone:919-815-0688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
05781225A00000X
NC7202101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6104086Medicaid