=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689554347
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LACY DAWN GREEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2025
-----------------------------------------------------
Last Update Date | 09/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 87 ELM ST
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65655-7131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-679-2775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1359
-----------------------------------------------------
City | AVA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65608-1359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-683-1111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2025037160
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------