Provider Demographics
NPI:1972272557
Name:HENNEKE, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:HENNEKE
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 1:545 W UMPQUA ST STE 1
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2979
Mailing Address - Country:US
Mailing Address - Phone:541-957-5646
Mailing Address - Fax:541-957-0191
Practice Address - Street 1:545 W UMPQUA ST STE 1
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2979
Practice Address - Country:US
Practice Address - Phone:541-957-5646
Practice Address - Fax:541-957-0191
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor