Provider Demographics
NPI:1376612523
Name:LACEY, KATHLEEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:LACEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11094 COUNTY ROAD 230
Mailing Address - Street 2:
Mailing Address - City:ORONOGO
Mailing Address - State:MO
Mailing Address - Zip Code:64855-8121
Mailing Address - Country:US
Mailing Address - Phone:405-226-2572
Mailing Address - Fax:
Practice Address - Street 1:11094 COUNTY ROAD 230
Practice Address - Street 2:
Practice Address - City:ORONOGO
Practice Address - State:MO
Practice Address - Zip Code:64855-8121
Practice Address - Country:US
Practice Address - Phone:405-226-2572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014039066103T00000X
OK3526103TC1900X
OK1048103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1376612523Medicaid
OK200052450Medicaid
OK200052450Medicaid