Provider Demographics
NPI:1609290154
Name:ANDERSON, LACEY (BCBA)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4058 W SHADY PLUM WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-3908
Mailing Address - Country:US
Mailing Address - Phone:801-735-3252
Mailing Address - Fax:
Practice Address - Street 1:4058 W SHADY PLUM WAY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-3908
Practice Address - Country:US
Practice Address - Phone:801-735-3252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11312885103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT271872788003Medicaid