Provider Demographics
NPI:1467293845
Name:GASAWAY, LYCEDIA
Entity type:Individual
Prefix:
First Name:LYCEDIA
Middle Name:
Last Name:GASAWAY
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 1:1967 EMILY ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-8024
Mailing Address - Country:US
Mailing Address - Phone:662-760-7963
Mailing Address - Fax:
Practice Address - Street 1:1967 EMILY ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-8024
Practice Address - Country:US
Practice Address - Phone:662-760-7963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-01
Last Update Date:2024-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010239101YP2500X
MS2004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional