Provider Demographics
NPI:1891015368
Name:WALLACE-CZIRJAK, LACEY MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:MARIE
Last Name:WALLACE-CZIRJAK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:LACEY
Other - Middle Name:M
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:4 MASON AVE
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816
Mailing Address - Country:US
Mailing Address - Phone:732-715-1877
Mailing Address - Fax:
Practice Address - Street 1:15 WEST PROSPECT STREET
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816
Practice Address - Country:US
Practice Address - Phone:732-254-0600
Practice Address - Fax:732-254-8606
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05313200104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker