Provider Demographics
NPI:1376221069
Name:WILSON, LACIE MARIE
Entity Type:Individual
Prefix:
First Name:LACIE
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACIE
Other - Middle Name:MARIE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3344 W DISCOVERY LOOP
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-1277
Mailing Address - Country:US
Mailing Address - Phone:907-232-2797
Mailing Address - Fax:
Practice Address - Street 1:7610 E PALMER WASILLA HWY
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-8467
Practice Address - Country:US
Practice Address - Phone:907-206-4421
Practice Address - Fax:907-726-5366
Is Sole Proprietor?:No
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician