Provider Demographics
NPI:1528954278
Name:SMITH, STACEY BOOE
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:BOOE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 CAMELOT DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-9415
Mailing Address - Country:US
Mailing Address - Phone:704-622-1605
Mailing Address - Fax:
Practice Address - Street 1:905 FRIEDBERG CHURCH RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-9803
Practice Address - Country:US
Practice Address - Phone:336-251-1180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-17
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician