Provider Demographics
NPI:1871898858
Name:SMITH, STACY (LPC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6423
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80424-6423
Mailing Address - Country:US
Mailing Address - Phone:970-389-6172
Mailing Address - Fax:
Practice Address - Street 1:100 SOUTH RIDGE ROAD
Practice Address - Street 2:SUITE 201 C
Practice Address - City:BRECKENRIDGE
Practice Address - State:CO
Practice Address - Zip Code:80424
Practice Address - Country:US
Practice Address - Phone:970-389-6172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4227101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health