Provider Demographics
NPI:1003181355
Name:ELLIOTT, LACEY MARIE (LPC - INTERN)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:MARIE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LPC - INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9708 SKILLMAN ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-5150
Mailing Address - Country:US
Mailing Address - Phone:214-863-8064
Mailing Address - Fax:214-932-1977
Practice Address - Street 1:9708 SKILLMAN ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-5150
Practice Address - Country:US
Practice Address - Phone:214-863-8064
Practice Address - Fax:214-932-1977
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68259101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX68259OtherLPC - INTERN