Provider Demographics
NPI:1457449787
Name:UTTERBACK, LACY ELIZABETH (IMF)
Entity Type:Individual
Prefix:MRS
First Name:LACY
Middle Name:ELIZABETH
Last Name:UTTERBACK
Suffix:
Gender:F
Credentials:IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11770 BERNARDO PLAZA CT
Mailing Address - Street 2:SUITE 260
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2422
Mailing Address - Country:US
Mailing Address - Phone:858-487-9050
Mailing Address - Fax:858-451-8453
Practice Address - Street 1:11770 BERNARDO PLAZA CT
Practice Address - Street 2:SUITE 260
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2422
Practice Address - Country:US
Practice Address - Phone:858-487-9050
Practice Address - Fax:858-451-8453
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44322106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist