Provider Demographics
NPI:1861908899
Name:CAMPBELL, LACEY MARIE RUDISILL (MS, LPC-MHSP)
Entity type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:MARIE RUDISILL
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MS, LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 BRICK PATH LN APT 307
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-3184
Mailing Address - Country:US
Mailing Address - Phone:704-648-8016
Mailing Address - Fax:
Practice Address - Street 1:2021 RICHARD JONES RD STE 350B
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37215-2871
Practice Address - Country:US
Practice Address - Phone:615-479-2859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3904101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional