Provider Demographics
NPI:1518331842
Name:AYLESWORTH, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:AYLESWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:SUNDERLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3905 87TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-6821
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3905 87TH AVE NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-6821
Practice Address - Country:US
Practice Address - Phone:425-350-5223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60611595235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist