Provider Demographics
NPI:1003655317
Name:WILKERSON, LACY (MD)
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LACY
Other - Middle Name:RAE
Other - Last Name:WILKERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LACY RAE HILL
Mailing Address - Street 1:1015 FM 272
Mailing Address - Street 2:
Mailing Address - City:CELESTE
Mailing Address - State:TX
Mailing Address - Zip Code:75423-6248
Mailing Address - Country:US
Mailing Address - Phone:615-208-0663
Mailing Address - Fax:
Practice Address - Street 1:1015 FM 272
Practice Address - Street 2:
Practice Address - City:CELESTE
Practice Address - State:TX
Practice Address - Zip Code:75423-6248
Practice Address - Country:US
Practice Address - Phone:615-208-0663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist