Provider Demographics
NPI:1376908764
Name:PINE, LACI RACHELLE
Entity Type:Individual
Prefix:MRS
First Name:LACI
Middle Name:RACHELLE
Last Name:PINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 TOP LN
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-9728
Mailing Address - Country:US
Mailing Address - Phone:360-748-3553
Mailing Address - Fax:
Practice Address - Street 1:8282 28TH CT NE
Practice Address - Street 2:SUITE A
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-7162
Practice Address - Country:US
Practice Address - Phone:360-915-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst