Provider Demographics
NPI:1891015855
Name:MCBRIDE, LACEY J (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:J
Last Name:MCBRIDE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:J
Other - Last Name:MONTIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CF-SLP
Mailing Address - Street 1:2522 E 70TH ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4002
Mailing Address - Country:US
Mailing Address - Phone:318-795-3388
Mailing Address - Fax:318-795-3399
Practice Address - Street 1:2522 E 70TH ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4002
Practice Address - Country:US
Practice Address - Phone:318-795-3388
Practice Address - Fax:318-795-3399
Is Sole Proprietor?:No
Enumeration Date:2010-06-01
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105034235Z00000X
LA6571235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist