Provider Demographics
NPI:1487472320
Name:LACOST, KELLY LAURA (THW, PSS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LAURA
Last Name:LACOST
Suffix:
Gender:F
Credentials:THW, PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1258 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3238
Mailing Address - Country:US
Mailing Address - Phone:541-337-1902
Mailing Address - Fax:
Practice Address - Street 1:261 E 12TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3208
Practice Address - Country:US
Practice Address - Phone:541-780-4277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR110535175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist