Provider Demographics
NPI:1376211193
Name:BACON, LAWRENCE ALLEN (LCASA, LCMHCA)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:ALLEN
Last Name:BACON
Suffix:
Gender:M
Credentials:LCASA, LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 CENTURY BLVD APT 47A
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-4038
Mailing Address - Country:US
Mailing Address - Phone:336-257-9384
Mailing Address - Fax:
Practice Address - Street 1:229 CENTURY BLVD APT 47A
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-4038
Practice Address - Country:US
Practice Address - Phone:336-257-9384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-06
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-27641101YA0400X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty