Provider Demographics
NPI:1871761460
Name:CAMPBELL, LACI JOLEE
Entity type:Individual
Prefix:MRS
First Name:LACI
Middle Name:JOLEE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344176 E 5000 RD
Mailing Address - Street 2:
Mailing Address - City:PAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74058-3751
Mailing Address - Country:US
Mailing Address - Phone:405-742-2943
Mailing Address - Fax:
Practice Address - Street 1:344176 E 5000 RD
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74058-3751
Practice Address - Country:US
Practice Address - Phone:405-742-2943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-15
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YA0400X
OK3563101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)