Provider Demographics
NPI:1649576174
Name:FLYNN, LACY OLIVIA (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LACY
Middle Name:OLIVIA
Last Name:FLYNN
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:RIB LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54470-9322
Mailing Address - Country:US
Mailing Address - Phone:715-427-5291
Mailing Address - Fax:
Practice Address - Street 1:457 S STATE ROAD 145
Practice Address - Street 2:
Practice Address - City:FRENCH LICK
Practice Address - State:IN
Practice Address - Zip Code:47432-1036
Practice Address - Country:US
Practice Address - Phone:812-936-9666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004475A235Z00000X
WI5085-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist