Provider Demographics
NPI:1982810867
Name:CAMP, LACY MIDDLEBROOKS (M ED)
Entity Type:Individual
Prefix:MS
First Name:LACY
Middle Name:MIDDLEBROOKS
Last Name:CAMP
Suffix:
Gender:F
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 N LUMPKIN ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-2744
Mailing Address - Country:US
Mailing Address - Phone:706-369-7911
Mailing Address - Fax:706-208-9509
Practice Address - Street 1:1690 S MILLEDGE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-1453
Practice Address - Country:US
Practice Address - Phone:706-369-7911
Practice Address - Fax:706-208-9509
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000967101Y00000X
GA000478106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor