Provider Demographics
NPI:1578997458
Name:YBARRA, LACIE L (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LACIE
Middle Name:L
Last Name:YBARRA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 SPRING VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:GERING
Mailing Address - State:NE
Mailing Address - Zip Code:69341-1622
Mailing Address - Country:US
Mailing Address - Phone:231-903-5499
Mailing Address - Fax:
Practice Address - Street 1:2616 AVENUE A
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-1635
Practice Address - Country:US
Practice Address - Phone:308-672-5759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013029466235Z00000X
NE1543235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1578997458Medicaid