Provider Demographics
NPI:1588950836
Name:PETERS, LACEY MICHELLE (MA, CCC-SLP/L)
Entity type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:MICHELLE
Last Name:PETERS
Suffix:
Gender:F
Credentials:MA, CCC-SLP/L
Other - Prefix:MISS
Other - First Name:LACEY
Other - Middle Name:MICHELLE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP/L
Mailing Address - Street 1:473 W ARMY TRAIL RD STE 107
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2674
Mailing Address - Country:US
Mailing Address - Phone:630-664-3510
Mailing Address - Fax:215-318-1772
Practice Address - Street 1:975 E NERGE RD STE W20
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:IL
Practice Address - Zip Code:60172-4812
Practice Address - Country:US
Practice Address - Phone:630-664-3510
Practice Address - Fax:215-318-1772
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-24
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.010677235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist