Provider Demographics
NPI:1578815627
Name:DAVIS, LACEY (MED PLPC)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MED PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 PLUM ST
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-3366
Mailing Address - Country:US
Mailing Address - Phone:573-253-0443
Mailing Address - Fax:
Practice Address - Street 1:2726 S CLARK ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-3803
Practice Address - Country:US
Practice Address - Phone:573-253-6939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011039351101YP2500X
MO390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program