Provider Demographics
NPI:1417212176
Name:LEROUX, LACEY (MSED)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:LEROUX
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:WADDINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:13694-0249
Mailing Address - Country:US
Mailing Address - Phone:315-388-7703
Mailing Address - Fax:315-388-4707
Practice Address - Street 1:10 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WADDINGTON
Practice Address - State:NY
Practice Address - Zip Code:13694-0249
Practice Address - Country:US
Practice Address - Phone:315-388-7703
Practice Address - Fax:315-388-4707
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY554567111174400000X
NY554566111174400000X
NY514001111174400000X
NY445519101174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist