Provider Demographics
NPI:1790285286
Name:LACY, MARTELA CARRON (BA)
Entity Type:Individual
Prefix:
First Name:MARTELA
Middle Name:CARRON
Last Name:LACY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 SOMERVILLE RD SE STE 1
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-4309
Mailing Address - Country:US
Mailing Address - Phone:256-260-7361
Mailing Address - Fax:256-350-5664
Practice Address - Street 1:1315 13TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4308
Practice Address - Country:US
Practice Address - Phone:256-260-7306
Practice Address - Fax:256-350-5664
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator