Provider Demographics
NPI:1114674314
Name:GUEST, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:GUEST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2985 N 935 E STE 7
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040-7318
Mailing Address - Country:US
Mailing Address - Phone:801-771-0273
Mailing Address - Fax:
Practice Address - Street 1:272 N BROADWAY ST STE 101
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-2244
Practice Address - Country:US
Practice Address - Phone:801-771-0273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-22-205700106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty