Provider Demographics
NPI:1215061254
Name:LACEY, AUDRA K (MFT)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:K
Last Name:LACEY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5480 BALTIMORE DR STE 103
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-2068
Mailing Address - Country:US
Mailing Address - Phone:619-559-8591
Mailing Address - Fax:619-271-7356
Practice Address - Street 1:5480 BALTIMORE DR STE 103
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2068
Practice Address - Country:US
Practice Address - Phone:619-559-8591
Practice Address - Fax:619-271-7356
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC38530106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist