1740681394 NPI number — MISS LACEY MARIE WILSON MS, LPC

Table of content: MISS LACEY MARIE WILSON MS, LPC (NPI 1740681394)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740681394 NPI number — MISS LACEY MARIE WILSON MS, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
LACEY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
MS, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740681394
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 PEBBLE CREEK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLARD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65781-8152
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-693-0120
Provider Business Mailing Address Fax Number:
417-222-3367

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 E JACKSON ST STE 3B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLARD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65781-9472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-693-0120
Provider Business Practice Location Address Fax Number:
417-222-3367
Provider Enumeration Date:
09/12/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  2014042626 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1740681394 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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