Provider Demographics
NPI:1578001855
Name:WILSON, LACEY N
Entity Type:Individual
Prefix:MS
First Name:LACEY
Middle Name:N
Last Name:WILSON
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 1:207D COLEGATE DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-2363
Mailing Address - Country:US
Mailing Address - Phone:740-376-0930
Mailing Address - Fax:740-376-0933
Practice Address - Street 1:207D COLEGATE DR
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-2363
Practice Address - Country:US
Practice Address - Phone:740-376-0930
Practice Address - Fax:740-376-0933
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.126395.MEDS-IV164W00000X
OHC.2102960-TRNE101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No164W00000XNursing Service ProvidersLicensed Practical Nurse