Healthcare Provider Details

I. General information

NPI: 1780910554
Provider Name (Legal Business Name): LACEY DAWN CARROLL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2009
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 S MADISON BLVD
BARTLESVILLE OK
74006-2822
US

IV. Provider business mailing address

245 S MADISON BLVD
BARTLESVILLE OK
74006-2822
US

V. Phone/Fax

Practice location:
  • Phone: 918-336-1463
  • Fax: 918-331-9717
Mailing address:
  • Phone: 918-336-1463
  • Fax: 918-331-9717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4937
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: