Provider Demographics
NPI:1417389743
Name:CARTER, LACEY JEAN (MS CCC SLP)
Entity Type:Individual
Prefix:MS
First Name:LACEY
Middle Name:JEAN
Last Name:CARTER
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 GLENDALE RD
Mailing Address - Street 2:
Mailing Address - City:NEWBERN
Mailing Address - State:TN
Mailing Address - Zip Code:38059-5118
Mailing Address - Country:US
Mailing Address - Phone:303-720-9160
Mailing Address - Fax:
Practice Address - Street 1:213 GLENDALE RD
Practice Address - Street 2:
Practice Address - City:NEWBERN
Practice Address - State:TN
Practice Address - Zip Code:38059
Practice Address - Country:US
Practice Address - Phone:303-720-9160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-09
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP0001902235Z00000X
KY4150235Z00000X
ASHA12157421235Z00000X
WALL60326759235Z00000X, 235Z00000X
TN0000004527235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1417389743Medicaid
WA1417389743Medicaid
TN1417389743Medicaid