Provider Demographics
NPI:1962783522
Name:MILLER, LACEY ANNE HEATH
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:ANNE HEATH
Last Name:MILLER
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 1:1730 NW COUCH ST APT 402
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2127
Mailing Address - Country:US
Mailing Address - Phone:210-410-1298
Mailing Address - Fax:
Practice Address - Street 1:5440 SW WESTGATE DR STE 350
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2447
Practice Address - Country:US
Practice Address - Phone:971-352-6971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC9011101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health