Provider Demographics
NPI:1003278334
Name:PICKETT, LACEY COLLEEN (MS, LPC)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:COLLEEN
Last Name:PICKETT
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1187
Mailing Address - Country:US
Mailing Address - Phone:276-223-3200
Mailing Address - Fax:276-223-0617
Practice Address - Street 1:540 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2209
Practice Address - Country:US
Practice Address - Phone:276-223-3291
Practice Address - Fax:276-223-3249
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6321101YP2500X
VA0701009787101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional