Provider Demographics
NPI:1265075311
Name:PHIPPS, LACI DAWN
Entity type:Individual
Prefix:
First Name:LACI
Middle Name:DAWN
Last Name:PHIPPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4304 OLD SCIOTO TRL
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-6672
Mailing Address - Country:US
Mailing Address - Phone:740-351-9298
Mailing Address - Fax:740-529-0593
Practice Address - Street 1:4300 OLD SCIOTO TRL
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-6642
Practice Address - Country:US
Practice Address - Phone:740-351-9298
Practice Address - Fax:740-529-0553
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH179292101YA0400X
101YM0800X
OHCDCA.179292101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty