Provider Demographics
NPI:1023554896
Name:LACY, SHACOLA (SUDCC #11319)
Entity Type:Individual
Prefix:MRS
First Name:SHACOLA
Middle Name:
Last Name:LACY
Suffix:
Gender:F
Credentials:SUDCC #11319
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4452 E KINGS CANYON RD
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93702
Mailing Address - Country:US
Mailing Address - Phone:559-600-9067
Mailing Address - Fax:559-600-6090
Practice Address - Street 1:4452 E KINGS CANYON RD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702
Practice Address - Country:US
Practice Address - Phone:559-600-9067
Practice Address - Fax:559-600-6090
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)