Basic Information
| Provider Information | |||||||||
| NPI: | 1174679062 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OWEN | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | SMOOT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5398 THOMASTON RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312208110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784768868 | ||||||||
| FaxNumber: | 4784768161 | ||||||||
| Practice Location | |||||||||
| Address1: | 5398 THOMASTON RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312208110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784768868 | ||||||||
| FaxNumber: | 4784768161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY003006 | GA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.