Provider Demographics
NPI:1376819326
Name:SALLIOTTE, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:SALLIOTTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:CARLTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1215 SW G ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2544
Mailing Address - Country:US
Mailing Address - Phone:541-476-2373
Mailing Address - Fax:541-774-7979
Practice Address - Street 1:200 BEATTY ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-5811
Practice Address - Country:US
Practice Address - Phone:541-476-2373
Practice Address - Fax:541-414-0740
Is Sole Proprietor?:No
Enumeration Date:2012-03-23
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC5493101YP2500X
OR101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional