Provider Demographics
NPI:1528705050
Name:LACE, JOHN WALTER (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WALTER
Last Name:LACE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 A AVE NE
Mailing Address - Street 2:PMR - NEUROPSYCHOLOGY
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402
Mailing Address - Country:US
Mailing Address - Phone:319-369-7211
Mailing Address - Fax:
Practice Address - Street 1:1026 A AVE NE
Practice Address - Street 2:PMR - NEUROPSYCHOLOGY
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402
Practice Address - Country:US
Practice Address - Phone:319-369-7211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA110965103G00000X, 103T00000X
WI5000-57103G00000X, 103T00000X
IA126559103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service