1508251034 NPI number — LACEY M MARKS LCSW

Table of content: LACEY M MARKS LCSW (NPI 1508251034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508251034 NPI number — LACEY M MARKS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARKS
Provider First Name:
LACEY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BEACHEM
Provider Other First Name:
LACEY
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508251034
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 SHENANGO AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHARON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16146-1503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-843-0314
Provider Business Mailing Address Fax Number:
724-843-0316

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1302 7TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAVER FALLS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15010-4217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-843-0314
Provider Business Practice Location Address Fax Number:
724-843-0316
Provider Enumeration Date:
04/01/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  SW130887 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: CW018950 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1030654040001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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