Provider Demographics
NPI:1285825398
Name:LACY, MICHAEL (PHD,, LBP, NCSP)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:LACY
Suffix:
Gender:M
Credentials:PHD,, LBP, NCSP
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 31331
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-0023
Mailing Address - Country:US
Mailing Address - Phone:405-285-1501
Mailing Address - Fax:405-285-5210
Practice Address - Street 1:2000 E 15TH ST STE 150C
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-6679
Practice Address - Country:US
Practice Address - Phone:405-919-2147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0238101YM0800X
OK22098103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool