Provider Demographics
NPI:1033794490
Name:LACEY, ABIGAIL SUSAN (MA)
Entity Type:Individual
Prefix:MRS
First Name:ABIGAIL
Middle Name:SUSAN
Last Name:LACEY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 MALLARD LN
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-3787
Mailing Address - Country:US
Mailing Address - Phone:850-603-0726
Mailing Address - Fax:
Practice Address - Street 1:3613 WILLIAMS DR STE 302
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-1369
Practice Address - Country:US
Practice Address - Phone:512-713-9886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH20788390200000X
TX91552101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program