Provider Demographics
NPI:1639415581
Name:MOON, LACY ELIZABETH (MSW U/S, LMSW)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:ELIZABETH
Last Name:MOON
Suffix:
Gender:F
Credentials:MSW U/S, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:OK
Mailing Address - Zip Code:73550-1436
Mailing Address - Country:US
Mailing Address - Phone:580-688-2800
Mailing Address - Fax:
Practice Address - Street 1:400 E SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:OK
Practice Address - Zip Code:73550-1436
Practice Address - Country:US
Practice Address - Phone:580-688-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-21
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 390200000X
OK5836-P101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program