Provider Demographics
NPI:1023512639
Name:LACIO, MICHAELA RUBY (MHR, LPC-C)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:RUBY
Last Name:LACIO
Suffix:
Gender:F
Credentials:MHR, LPC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3743 S 213TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-1231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3100 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-1088
Practice Address - Country:US
Practice Address - Phone:918-342-0770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK171M00000XMedicaid