Provider Demographics
NPI:1740681394
Name:WILSON, LACEY MARIE (MS, LPC)
Entity type:Individual
Prefix:MISS
First Name:LACEY
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
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Mailing Address - Street 1:105 PEBBLE CREEK LN
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:MO
Mailing Address - Zip Code:65781-8152
Mailing Address - Country:US
Mailing Address - Phone:417-693-0120
Mailing Address - Fax:417-222-3367
Practice Address - Street 1:304 E JACKSON ST STE 3B
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:MO
Practice Address - Zip Code:65781-9472
Practice Address - Country:US
Practice Address - Phone:417-693-0120
Practice Address - Fax:417-222-3367
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-12
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014042626101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1740681394Medicaid