Provider Demographics
NPI:1508686742
Name:PETERS, LACIE J
Entity type:Individual
Prefix:
First Name:LACIE
Middle Name:J
Last Name:PETERS
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 1:10240 N VASSAR RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:MI
Mailing Address - Zip Code:48458-9718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10240 N VASSAR RD
Practice Address - Street 2:
Practice Address - City:MOUNT MORRIS
Practice Address - State:MI
Practice Address - Zip Code:48458-9718
Practice Address - Country:US
Practice Address - Phone:810-350-8254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst