Provider Demographics
NPI:1629887880
Name:LACY, DEJA AMARI
Entity type:Individual
Prefix:
First Name:DEJA
Middle Name:AMARI
Last Name:LACY
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 1:46 WASHINGTON AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-5608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:780 LYNNHAVEN PKWY STE 400
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7332
Practice Address - Country:US
Practice Address - Phone:877-276-0626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-02
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-23-270420106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician