Provider Demographics
NPI:1558939538
Name:KELLEY, LACEY LEEANN (M ED)
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:LEEANN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:M ED
Other - Prefix:MS
Other - First Name:LACEY
Other - Middle Name:LEEAN
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5264 NE 121ST AVE APT M106
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-2157
Mailing Address - Country:US
Mailing Address - Phone:360-261-1419
Mailing Address - Fax:
Practice Address - Street 1:300 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:WA
Practice Address - Zip Code:98577-3016
Practice Address - Country:US
Practice Address - Phone:360-942-2303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA91-1324228101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1174570949Medicaid