Provider Demographics
NPI:1649549098
Name:BRUICK, LACIE DEANN (MSCCCSLP)
Entity type:Individual
Prefix:
First Name:LACIE
Middle Name:DEANN
Last Name:BRUICK
Suffix:
Gender:F
Credentials:MSCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 ELIZABETH ST
Mailing Address - Street 2:CONWAY
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:313 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-6335
Practice Address - Country:US
Practice Address - Phone:501-744-0329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-14
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#3089235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist