Provider Demographics
NPI:1316344542
Name:MARY LUCAS LACEY
Entity type:Organization
Organization Name:MARY LUCAS LACEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LUCAS
Authorized Official - Last Name:LACEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, DBH
Authorized Official - Phone:704-421-5505
Mailing Address - Street 1:3420 PLANTATION RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-0729
Mailing Address - Country:US
Mailing Address - Phone:704-421-5505
Mailing Address - Fax:
Practice Address - Street 1:3420 PLANTATION RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-0729
Practice Address - Country:US
Practice Address - Phone:704-421-5505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLPC3459251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health