Healthcare Provider Details

I. General information

NPI: 1447813365
Provider Name (Legal Business Name): LACEY BRINLEE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 03/29/2026
Certification Date: 03/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2548 E KENOSHA ST
BROKEN ARROW OK
74014-6712
US

IV. Provider business mailing address

2548 E KENOSHA ST
BROKEN ARROW OK
74014-6712
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone: --
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number10320
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: