Provider Demographics
NPI:1215561915
Name:BANGERT, LACY RENAE (LPC)
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:RENAE
Last Name:BANGERT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16025 W LILAC ST
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-2878
Mailing Address - Country:US
Mailing Address - Phone:307-630-0511
Mailing Address - Fax:
Practice Address - Street 1:16025 W LILAC ST
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-2878
Practice Address - Country:US
Practice Address - Phone:307-630-0511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC8769101YP2500X
CO0017704101YP2500X
AZ23036101YP2500X
WY1675101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional