Provider Demographics
NPI:1346256328
Name:LACY, STEPHANIE (LCSW & LMFT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:LACY
Suffix:
Gender:F
Credentials:LCSW & LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 908023
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-0916
Mailing Address - Country:US
Mailing Address - Phone:770-534-8832
Mailing Address - Fax:770-531-7479
Practice Address - Street 1:142 FORREST AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:404-345-7062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA734106H00000X
GA15021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA935374Medicare UPIN
GA80BBFXJMedicare ID - Type Unspecified