Provider Demographics
NPI:1932431749
Name:LACEY, LEESA
Entity Type:Individual
Prefix:
First Name:LEESA
Middle Name:
Last Name:LACEY
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 1:3121 NW 54TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5308
Mailing Address - Country:US
Mailing Address - Phone:405-205-8326
Mailing Address - Fax:
Practice Address - Street 1:3535 NW 58TH ST.
Practice Address - Street 2:SUITE 870
Practice Address - City:OKC
Practice Address - State:OK
Practice Address - Zip Code:73112
Practice Address - Country:US
Practice Address - Phone:405-702-9032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health