Provider Demographics
NPI:1720461064
Name:HAMMOND, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:HAMMOND
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 1:121 11TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-1850
Mailing Address - Country:US
Mailing Address - Phone:651-777-5222
Mailing Address - Fax:651-251-5279
Practice Address - Street 1:121 11TH AVE SE
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-1850
Practice Address - Country:US
Practice Address - Phone:651-777-5222
Practice Address - Fax:651-251-5279
Is Sole Proprietor?:No
Enumeration Date:2015-07-06
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN220811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical