Provider Demographics
NPI:1477000347
Name:CLARK, LACEY GREEN
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:GREEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:5419 HIGHWAY 25 STE R
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-6343
Mailing Address - Country:US
Mailing Address - Phone:601-479-5392
Mailing Address - Fax:
Practice Address - Street 1:5419 HIGHWAY 25 STE R
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-6343
Practice Address - Country:US
Practice Address - Phone:601-479-5392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1384225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist