Provider Demographics
NPI:1902158918
Name:ALLEN WATKINS, LACY MICHELLE (LMHC, CAP, DCC)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:MICHELLE
Last Name:ALLEN WATKINS
Suffix:
Gender:F
Credentials:LMHC, CAP, DCC
Other - Prefix:
Other - First Name:LACY
Other - Middle Name:MICHELLE
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC, CAP, DCC
Mailing Address - Street 1:704 SAMUEL CHASE LN
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-7501
Mailing Address - Country:US
Mailing Address - Phone:321-432-5119
Mailing Address - Fax:
Practice Address - Street 1:906 PEACHTREE ST
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7223
Practice Address - Country:US
Practice Address - Phone:321-806-2846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5544101YA0400X
FLMH11112101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)