Provider Demographics
NPI:1417624859
Name:BUCKELEW, LACEY JANE (ASW)
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:JANE
Last Name:BUCKELEW
Suffix:
Gender:F
Credentials:ASW
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 735
Mailing Address - Street 2:1927 HARBOR BLVD.
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627
Mailing Address - Country:US
Mailing Address - Phone:714-651-1869
Mailing Address - Fax:
Practice Address - Street 1:301 VICTORIA ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-1995
Practice Address - Country:US
Practice Address - Phone:949-574-3367
Practice Address - Fax:949-999-6192
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1034341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical