Provider Demographics
NPI:1437334729
Name:LACEY, LARRY G (MSW)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:G
Last Name:LACEY
Suffix:
Gender:M
Credentials:MSW
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 645
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702-0645
Mailing Address - Country:US
Mailing Address - Phone:573-335-7929
Mailing Address - Fax:573-335-6445
Practice Address - Street 1:1221 N KINGSHIGHWAY ST
Practice Address - Street 2:IMPERIAL BUILDING
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-3506
Practice Address - Country:US
Practice Address - Phone:573-335-7929
Practice Address - Fax:573-335-6445
Is Sole Proprietor?:No
Enumeration Date:2008-01-04
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060336511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical