Provider Demographics
NPI:1720101678
Name:LACEWELL, MISTY MICHELLE (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MISTY
Middle Name:MICHELLE
Last Name:LACEWELL
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MRS
Other - First Name:MISTY
Other - Middle Name:LACEWELL
Other - Last Name:CONNERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:2401 BLACKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72207
Mailing Address - Country:US
Mailing Address - Phone:501-681-8148
Mailing Address - Fax:
Practice Address - Street 1:6124 NORTHMOOR DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-2504
Practice Address - Country:US
Practice Address - Phone:501-614-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-07
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1730235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR137364721Medicaid