Provider Demographics
NPI:1609350347
Name:QUINBY, LACEY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:QUINBY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4259 OAK FOREST DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-0854
Mailing Address - Country:US
Mailing Address - Phone:229-329-7409
Mailing Address - Fax:
Practice Address - Street 1:4259 OAK FOREST DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-0854
Practice Address - Country:US
Practice Address - Phone:229-329-7409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET002791235Z00000X
GA010905235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA47-2746468Medicaid