Provider Demographics
NPI:1942738224
Name:MAYDON, LACEY LYNN (MSW)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:LYNN
Last Name:MAYDON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 PRINCETON ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-4409
Mailing Address - Country:US
Mailing Address - Phone:989-316-2252
Mailing Address - Fax:
Practice Address - Street 1:1714 EASTMAN AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4216
Practice Address - Country:US
Practice Address - Phone:989-631-5390
Practice Address - Fax:989-631-0488
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011010841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical