Provider Demographics
NPI:1215397450
Name:LACEY, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:LACEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14801 NORDHOFF ST
Mailing Address - Street 2:APT 217
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-1500
Mailing Address - Country:US
Mailing Address - Phone:313-492-7073
Mailing Address - Fax:
Practice Address - Street 1:16500 VENTURA BLVD
Practice Address - Street 2:SUITE 414
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2011
Practice Address - Country:US
Practice Address - Phone:818-788-1003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst