Provider Demographics
NPI:1700297884
Name:REMINGTON, LACEY NICOLE (SSP)
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:NICOLE
Last Name:REMINGTON
Suffix:
Gender:F
Credentials:SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 JAMESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-9400
Mailing Address - Country:US
Mailing Address - Phone:309-313-1289
Mailing Address - Fax:
Practice Address - Street 1:145 JAMESTOWN RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-9400
Practice Address - Country:US
Practice Address - Phone:309-313-1289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1795788103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool