1881033843 NPI number — MRS. INGRID JENNIFER LACEY LPC, BC-DMT, GLCMA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881033843 NPI number — MRS. INGRID JENNIFER LACEY LPC, BC-DMT, GLCMA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LACEY
Provider First Name:
INGRID
Provider Middle Name:
JENNIFER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC, BC-DMT, GLCMA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881033843
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2156 CAVANAUGH AVE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30316-2706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-913-8831
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1799 CLAIRMONT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-913-8831
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/22/2013

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: 101Y00000X , with the licence number:  LPC 206 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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