Provider Demographics
NPI:1407619513
Name:LACEY, MCKENNA JOANNE
Entity Type:Individual
Prefix:MISS
First Name:MCKENNA
Middle Name:JOANNE
Last Name:LACEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3048 S CLIFTON AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-6045
Mailing Address - Country:US
Mailing Address - Phone:417-818-5784
Mailing Address - Fax:
Practice Address - Street 1:3048 S CLIFTON AVE STE 112
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-6045
Practice Address - Country:US
Practice Address - Phone:417-818-5784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORBT-23-271007106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician