Provider Demographics
NPI:1891379046
Name:CHURCH, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:CHURCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9750 N ORACLE RD APT 14107
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-7683
Mailing Address - Country:US
Mailing Address - Phone:623-217-0882
Mailing Address - Fax:
Practice Address - Street 1:1580 N KOLB RD STE 206
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-4933
Practice Address - Country:US
Practice Address - Phone:520-214-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-19410104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker