Provider Demographics
NPI:1881033843
Name:LACEY, INGRID JENNIFER (LPC, BC-DMT, GLCMA)
Entity Type:Individual
Prefix:MRS
First Name:INGRID
Middle Name:JENNIFER
Last Name:LACEY
Suffix:
Gender:F
Credentials:LPC, BC-DMT, GLCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2156 CAVANAUGH AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-2706
Mailing Address - Country:US
Mailing Address - Phone:415-913-8831
Mailing Address - Fax:
Practice Address - Street 1:1799 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033
Practice Address - Country:US
Practice Address - Phone:415-913-8831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-22
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPC 206101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor