Provider Demographics
NPI:1275961732
Name:TWARDOWSKI, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:TWARDOWSKI
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 1:3030 S 9TH ST
Mailing Address - Street 2:SUITE 3E
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-7956
Mailing Address - Country:US
Mailing Address - Phone:269-544-7720
Mailing Address - Fax:
Practice Address - Street 1:3030 S 9TH ST
Practice Address - Street 2:SUITE 3E
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-7956
Practice Address - Country:US
Practice Address - Phone:269-544-7720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-21
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015738101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor