Provider Demographics
NPI:1699188755
Name:GROVENSTEIN, LACY LOUANE
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:LOUANE
Last Name:GROVENSTEIN
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:PO BOX 1029
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-1029
Mailing Address - Country:US
Mailing Address - Phone:907-543-6800
Mailing Address - Fax:907-543-7101
Practice Address - Street 1:5106 NOEL POLTY BLVD
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559-1029
Practice Address - Country:US
Practice Address - Phone:907-543-6800
Practice Address - Fax:907-543-7101
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020986Medicaid
AK1584987Medicaid
AK1006017Medicaid