Provider Demographics
NPI:1083738363
Name:NICKERSON, LACEY LEE (MS, CCP)
Entity Type:Individual
Prefix:MS
First Name:LACEY
Middle Name:LEE
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:MS, CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16970 STRAWBERRY DR
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-3857
Mailing Address - Country:US
Mailing Address - Phone:310-210-0974
Mailing Address - Fax:
Practice Address - Street 1:16970 STRAWBERRY DR
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-3857
Practice Address - Country:US
Practice Address - Phone:310-210-0974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other