Provider Demographics
NPI:1710494315
Name:GRAFFAM, LACEY MARIE (MS, LCPC)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:MARIE
Last Name:GRAFFAM
Suffix:
Gender:F
Credentials:MS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 DEER CROSSING RD
Mailing Address - Street 2:
Mailing Address - City:LIMERICK
Mailing Address - State:ME
Mailing Address - Zip Code:04048-3418
Mailing Address - Country:US
Mailing Address - Phone:207-432-4007
Mailing Address - Fax:
Practice Address - Street 1:63 OCEAN ST UNIT B
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2828
Practice Address - Country:US
Practice Address - Phone:207-432-4007
Practice Address - Fax:207-774-9299
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MECC6373101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1710494315Medicaid