Provider Demographics
NPI:1720627219
Name:LAIRD, LACEY L (MHP)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:L
Last Name:LAIRD
Suffix:
Gender:F
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14340 N PUMP HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-8740
Mailing Address - Country:US
Mailing Address - Phone:618-204-2647
Mailing Address - Fax:
Practice Address - Street 1:4110 N WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6295
Practice Address - Country:US
Practice Address - Phone:618-242-8266
Practice Address - Fax:618-242-1150
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health