Provider Demographics
NPI:1710462544
Name:WATSON, LACEY CAMERON (LPC)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:CAMERON
Last Name:WATSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-4204
Mailing Address - Country:US
Mailing Address - Phone:630-251-2387
Mailing Address - Fax:
Practice Address - Street 1:122 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-4204
Practice Address - Country:US
Practice Address - Phone:630-251-2387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178013658101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty