Provider Demographics
NPI:1760690960
Name:LACY, RACHEL KELLI (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RACHEL
Middle Name:KELLI
Last Name:LACY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:RACHEL
Other - Middle Name:
Other - Last Name:LACY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 58
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-0001
Mailing Address - Country:US
Mailing Address - Phone:770-722-7827
Mailing Address - Fax:770-962-1886
Practice Address - Street 1:1805 HERRINGTON RD
Practice Address - Street 2:BUILDING 3, STE. 3-B
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-7987
Practice Address - Country:US
Practice Address - Phone:770-722-7827
Practice Address - Fax:770-760-0624
Is Sole Proprietor?:No
Enumeration Date:2007-05-19
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002801103TA0700X, 103TB0200X, 103TC0700X, 103TF0200X, 103TH0004X, 103TM1800X, 103TR0400X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00318238Medicare ID - Type UnspecifiedMEDICARE RAILROAD CARRIER
GAQ42064Medicare UPIN
GA68BBGMZMedicare ID - Type UnspecifiedMEDICARE PART B