Provider Demographics
NPI:1083901318
Name:NOONAN, LACEY (MFT, NCC)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:NOONAN
Suffix:
Gender:F
Credentials:MFT, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5435 COLLEGE AVE STE 202-7
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1598
Mailing Address - Country:US
Mailing Address - Phone:619-729-2395
Mailing Address - Fax:619-729-2395
Practice Address - Street 1:5435 COLLEGE AVE STE 202-7
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1598
Practice Address - Country:US
Practice Address - Phone:619-729-2395
Practice Address - Fax:619-729-2395
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 50196106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist