Provider Demographics
NPI:1548379266
Name:SMITH, STEPHANIE JANE (LPC)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:JANE
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 1:40 BOLIVIA ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2843
Mailing Address - Country:US
Mailing Address - Phone:860-423-5353
Mailing Address - Fax:860-423-5353
Practice Address - Street 1:40 BOLIVIA ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2843
Practice Address - Country:US
Practice Address - Phone:860-423-5353
Practice Address - Fax:860-423-5353
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001292101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
322796OtherMHN
CT240001292CT01OtherANTHEM BCBS
CT11244656OtherCAQH