Provider Demographics
NPI:1336498302
Name:BAKER, LACEY DIANE (LMSW, VSP)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:DIANE
Last Name:BAKER
Suffix:
Gender:F
Credentials:LMSW, VSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 HUGER ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-4320
Mailing Address - Country:US
Mailing Address - Phone:864-431-0089
Mailing Address - Fax:
Practice Address - Street 1:1615 AUGUSTA RD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-5629
Practice Address - Country:US
Practice Address - Phone:803-791-1511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical