Provider Demographics
NPI:1336592823
Name:ROOF, LACEY (MED)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:ROOF
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-6122
Mailing Address - Country:US
Mailing Address - Phone:270-899-0424
Mailing Address - Fax:270-721-6628
Practice Address - Street 1:641 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-1056
Practice Address - Country:US
Practice Address - Phone:270-899-0424
Practice Address - Fax:270-721-6628
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY282840103T00000X
KY361757103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist