Provider Demographics
NPI:1982937652
Name:STATON, LACEY JANE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:JANE
Last Name:STATON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 MARIA LN
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-8012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1335 MARIA LN
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-8012
Practice Address - Country:US
Practice Address - Phone:317-965-0694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004563A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist