Provider Demographics
NPI:1801466842
Name:MOLLOHAN, LACEY DONN
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:DONN
Last Name:MOLLOHAN
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 1:10947 CONNALLY LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8337
Mailing Address - Country:US
Mailing Address - Phone:828-320-3547
Mailing Address - Fax:
Practice Address - Street 1:160 S WINSTEAD AVE # 3419
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-3419
Practice Address - Country:US
Practice Address - Phone:252-443-7666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14660235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist