MEDICARE: LACEY REIKOWSKY, LPC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	4300	OK
2	101YM0800X	Mental Health Counselor	4300	OK
3	101YP2500X	Professional Counselor	4300	OK

General Provider Information

NPI Number	:	1295117356
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LACEY REIKOWSKY, LPC, LLC

Provider Business Mailing Address
First Line	:	620 SW 24TH ST
Second Line	:
City	:	MOORE
State	:	OK
Zip	:	73160-5515
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 UNITED FOUNDERS BLVD STE 148
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-4290
Country	:	US
Telephone Number	:	405-401-5725
Fax Number	:

Authorized Official
Title or Position	:	LICENSED PROFESSIONAL COUNSELOR
Name	:	LACEY REIKOWSKY
Credential	:	LPC
Telephone Number	:	405-401-5725

Provider Enumeration Date	:	06/25/2015
Last Update Date	:	06/25/2015

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