Provider Demographics
NPI:1902590979
Name:RUPP, LACEY LEE ELIZABETH (SLP)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:LEE ELIZABETH
Last Name:RUPP
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5726 FIELDCREST DR
Mailing Address - Street 2:
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21162-1143
Mailing Address - Country:US
Mailing Address - Phone:443-623-5950
Mailing Address - Fax:
Practice Address - Street 1:2018 ROCK SPRING RD
Practice Address - Street 2:
Practice Address - City:FOREST HILL
Practice Address - State:MD
Practice Address - Zip Code:21050-2631
Practice Address - Country:US
Practice Address - Phone:443-619-7712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02666235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist