Healthcare Provider Details

I. General information

NPI: 1508430695
Provider Name (Legal Business Name): MISTY MARIE LAWRENCE LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISTY MARIE COOPER

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 35TH AVE
COLUMBUS NE
68601-4731
US

IV. Provider business mailing address

617 NE GLENDALE AVE
PEORIA IL
61603
US

V. Phone/Fax

Practice location:
  • Phone: 402-562-6767
  • Fax:
Mailing address:
  • Phone: 309-624-9522
  • Fax: 309-624-9555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180018121
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: