Provider Demographics
NPI:1306338108
Name:PORTER, LACEY ADAIRE
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:ADAIRE
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 SPRING ST UNIT 3
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-4696
Mailing Address - Country:US
Mailing Address - Phone:678-877-5026
Mailing Address - Fax:
Practice Address - Street 1:2020 N ACADEMY BLVD STE 278
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1568
Practice Address - Country:US
Practice Address - Phone:719-322-5137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst