Provider Demographics
NPI:1992075808
Name:BENTON, LACY RENEE
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:RENEE
Last Name:BENTON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 E PATTERSON ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-1068
Mailing Address - Country:US
Mailing Address - Phone:813-389-3270
Mailing Address - Fax:
Practice Address - Street 1:26844 TANIC DR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-4616
Practice Address - Country:US
Practice Address - Phone:813-710-3014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2025-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-22-57744103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst