Healthcare Provider Details

I. General information

NPI: 1710892658
Provider Name (Legal Business Name): LACEY GLYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 W TAYLOR ST
VANDALIA IL
62471-1227
US

IV. Provider business mailing address

1455 N 430 ST
VANDALIA IL
62471-4049
US

V. Phone/Fax

Practice location:
  • Phone: 618-283-1232
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: