Provider Demographics
NPI:1023225992
Name:LACE, MILLIE F (MSE, LPC)
Entity type:Individual
Prefix:MRS
First Name:MILLIE
Middle Name:F
Last Name:LACE
Suffix:
Gender:F
Credentials:MSE, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 FORREST AVE E
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-3730
Mailing Address - Country:US
Mailing Address - Phone:870-238-4329
Mailing Address - Fax:870-208-8935
Practice Address - Street 1:202 COMMERCIAL AVE E
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-2930
Practice Address - Country:US
Practice Address - Phone:870-238-4329
Practice Address - Fax:870-208-8935
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP0011032101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5U380Medicare UPIN