Provider Demographics
NPI:1093020786
Name:CHAVIS, LACY (PSYD)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:CHAVIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 6TH ST S STE 420
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4825
Mailing Address - Country:US
Mailing Address - Phone:727-767-8477
Mailing Address - Fax:727-767-8244
Practice Address - Street 1:880 6TH ST S STE 420
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4825
Practice Address - Country:US
Practice Address - Phone:727-767-8477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103T00000X
FLPY8429103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWVE061OtherAGENCY MEDICARE ID#
NY1285628552OtherAGENCY NPI #
NY00355940OtherAGENCY MEDICAID PROVIDER ID