Healthcare Provider Details

I. General information

NPI: 1649576174
Provider Name (Legal Business Name): LACY OLIVIA FLYNN M.A. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

457 S STATE ROAD 145
FRENCH LICK IN
47432-1036
US

IV. Provider business mailing address

650 PEARL ST
RIB LAKE WI
54470-9322
US

V. Phone/Fax

Practice location:
  • Phone: 812-936-9666
  • Fax:
Mailing address:
  • Phone: 715-427-5291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22004475A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5085-154
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: