Provider Demographics
NPI:1902413685
Name:ANDREWS, LACEY LAVERNE (ANMT)
Entity Type:Individual
Prefix:MISS
First Name:LACEY
Middle Name:LAVERNE
Last Name:ANDREWS
Suffix:
Gender:F
Credentials:ANMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-1625
Mailing Address - Country:US
Mailing Address - Phone:707-703-0997
Mailing Address - Fax:
Practice Address - Street 1:400 SUMMIT DR
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-1625
Practice Address - Country:US
Practice Address - Phone:707-703-0997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43394225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist