Provider Demographics
NPI:1013061555
Name:LACEY, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:LACEY
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 1:2317 FRUITVALE AVE
Mailing Address - Street 2:APT 201
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2550
Mailing Address - Country:US
Mailing Address - Phone:415-240-1566
Mailing Address - Fax:
Practice Address - Street 1:7200 BANCROFT AVE STE 125C
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2454
Practice Address - Country:US
Practice Address - Phone:415-240-1566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA346461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1013061555OtherCHILDREN'S SPECIALIZED SERVICES