Provider Demographics
NPI:1093367898
Name:BERRY, LACEY (LPC)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:PIERCE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65723-2100
Mailing Address - Country:US
Mailing Address - Phone:417-476-1013
Mailing Address - Fax:417-476-1082
Practice Address - Street 1:1701 N CENTRAL
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708-6570
Practice Address - Country:US
Practice Address - Phone:417-235-6610
Practice Address - Fax:417-476-1082
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017016861101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional