Provider Demographics
NPI:1871670307
Name:LACEY, KATHLEEN CONNOLLY (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:CONNOLLY
Last Name:LACEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7464
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94120-7464
Mailing Address - Country:US
Mailing Address - Phone:415-206-3103
Mailing Address - Fax:415-206-3872
Practice Address - Street 1:939 MARKET STREET
Practice Address - Street 2:4TH FLOOR
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103
Practice Address - Country:US
Practice Address - Phone:415-597-8000
Practice Address - Fax:415-597-8004
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS203881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q48570Medicare UPIN
CAZZZ03600ZMedicare ID - Type Unspecified