Provider Demographics
NPI:1174050124
Name:SMITH, STACY COSTOPOULOS (LMFT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:COSTOPOULOS
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:COSTOPOULOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3088 PIO PICO DR STE 203
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1965
Mailing Address - Country:US
Mailing Address - Phone:760-494-4394
Mailing Address - Fax:
Practice Address - Street 1:3088 PIO PICO DR STE 203
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1965
Practice Address - Country:US
Practice Address - Phone:760-494-4394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-20
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122299106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist