Provider Demographics
NPI:1336836279
Name:PRINE, LACEY AMANDA
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:AMANDA
Last Name:PRINE
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 1:10863 BOYETTE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-8012
Mailing Address - Country:US
Mailing Address - Phone:813-444-8760
Mailing Address - Fax:
Practice Address - Street 1:1802 N ARMENIA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-3406
Practice Address - Country:US
Practice Address - Phone:813-444-8760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1375103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool