Provider Demographics
NPI:1295270957
Name:LACEY, WILFRED
Entity type:Individual
Prefix:
First Name:WILFRED
Middle Name:
Last Name:LACEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:FRED
Other - Middle Name:E
Other - Last Name:LACEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 35
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30292-0035
Mailing Address - Country:US
Mailing Address - Phone:770-856-0049
Mailing Address - Fax:770-567-3359
Practice Address - Street 1:2821 US HWY 19
Practice Address - Street 2:BOX 440
Practice Address - City:MEANSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30256-2243
Practice Address - Country:US
Practice Address - Phone:770-567-8987
Practice Address - Fax:770-567-3359
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC002574101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional