Provider Demographics
NPI:1912262148
Name:SMITH, STACY DOUGLAS (AT,C)
Entity Type:Individual
Prefix:MR
First Name:STACY
Middle Name:DOUGLAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 JOHNSON AVE
Mailing Address - Street 2:SHABAZZ
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07108
Mailing Address - Country:US
Mailing Address - Phone:973-744-4113
Mailing Address - Fax:
Practice Address - Street 1:80 JOHNSON AVE
Practice Address - Street 2:SHABAZZ
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07108
Practice Address - Country:US
Practice Address - Phone:973-744-4113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2016-06-14
Deactivation Date:2012-08-10
Deactivation Code:
Reactivation Date:2016-06-14
Provider Licenses
StateLicense IDTaxonomies
NJ25MT000375002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer