Healthcare Provider Details

I. General information

NPI: 1659621571
Provider Name (Legal Business Name): LACY OVERLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2803 CREEK DR STE D
JONESBORO AR
72401-5377
US

IV. Provider business mailing address

505 OLD CANYON RD
JONESBORO AR
72404-9406
US

V. Phone/Fax

Practice location:
  • Phone: 870-340-2636
  • Fax:
Mailing address:
  • Phone: 662-321-0728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number408
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP2408023
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: