Provider Demographics
NPI:1881946945
Name:ROSS, LACIE DOMINGUE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LACIE
Middle Name:DOMINGUE
Last Name:ROSS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:19005 FALLER RD
Mailing Address - Street 2:
Mailing Address - City:TICKFAW
Mailing Address - State:LA
Mailing Address - Zip Code:70466-2815
Mailing Address - Country:US
Mailing Address - Phone:985-662-2555
Mailing Address - Fax:985-898-2289
Practice Address - Street 1:201 HOLIDAY BLVD
Practice Address - Street 2:STE 315
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-5088
Practice Address - Country:US
Practice Address - Phone:985-898-2999
Practice Address - Fax:985-898-2289
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5714235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist