Provider Demographics
NPI:1386192532
Name:WALTHER, LACY (LAC)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:WALTHER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10799 N 90TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6110
Mailing Address - Country:US
Mailing Address - Phone:480-804-0326
Mailing Address - Fax:
Practice Address - Street 1:10799 N 90TH ST STE 100
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6110
Practice Address - Country:US
Practice Address - Phone:480-804-0326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2022-03-04
Deactivation Date:2018-03-26
Deactivation Code:
Reactivation Date:2019-10-24
Provider Licenses
StateLicense IDTaxonomies
AZLAC-13496101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health