Healthcare Provider Details

I. General information

NPI: 1750608071
Provider Name (Legal Business Name): LACY G DYKE MMFT, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2010
Last Update Date: 08/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 CYPRESS CREEK RD STE 301
CEDAR PARK TX
78613-4469
US

IV. Provider business mailing address

PO BOX 223
LEANDER TX
78646-0223
US

V. Phone/Fax

Practice location:
  • Phone: 512-912-6609
  • Fax:
Mailing address:
  • Phone: 512-912-6609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number63364
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number63364
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number63364
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: