Provider Demographics
NPI:1457738270
Name:WOLTER, LACY MARIE (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:MARIE
Last Name:WOLTER
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:LACY
Other - Middle Name:MARIE
Other - Last Name:GRIESSEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:17390 DUGDALE DR STE 100
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1512
Practice Address - Country:US
Practice Address - Phone:574-400-2169
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-16-24012103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst