MEDICARE: LACEY DANIELLE CAMPBELL LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	C017628	NC

General Provider Information

NPI Number	:	1144008582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACEY DANIELLE CAMPBELL LCSW

Provider Business Mailing Address
First Line	:	2643 MCCURDY TRL
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-4553
Country	:	US
Telephone Number	:	704-352-3469
Fax Number	:

Provider Business Practice Location Address
First Line	:	3205 FREEDOM DR STE 2000
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28208-3486
Country	:	US
Telephone Number	:	980-257-4811
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2023
Last Update Date	:	12/16/2024

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