Healthcare Provider Details

I. General information

NPI: 1801726989
Provider Name (Legal Business Name): LACEY KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 E CHAPPELL RD
MC CONNELLS SC
29726-8758
US

IV. Provider business mailing address

1940 E CHAPPELL RD
MC CONNELLS SC
29726-8758
US

V. Phone/Fax

Practice location:
  • Phone: 203-258-0250
  • Fax:
Mailing address:
  • Phone: 203-258-0250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number325956
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: