Provider Demographics
NPI:1639618473
Name:BRADLEY, LACEY DANSBY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:DANSBY
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:DAWN
Other - Last Name:DANSBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13808 NE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-8117
Mailing Address - Country:US
Mailing Address - Phone:405-503-2827
Mailing Address - Fax:
Practice Address - Street 1:4300 N LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-5107
Practice Address - Country:US
Practice Address - Phone:405-425-0364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health