Provider Demographics
NPI:1508532680
Name:WALL, LACEY SUTTLES (RBT)
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:SUTTLES
Last Name:WALL
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ELROD CT
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29306
Mailing Address - Country:US
Mailing Address - Phone:864-767-4400
Mailing Address - Fax:
Practice Address - Street 1:200 ELROD CT
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29306
Practice Address - Country:US
Practice Address - Phone:864-767-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician