Provider Demographics
NPI:1740453554
Name:LACEY-GENGELBACH, EUGENIA GAIL (ACSW LCSW)
Entity type:Individual
Prefix:MRS
First Name:EUGENIA
Middle Name:GAIL
Last Name:LACEY-GENGELBACH
Suffix:
Gender:F
Credentials:ACSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4476 S US HIGHWAY 31
Mailing Address - Street 2:
Mailing Address - City:CROTHERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47229-9647
Mailing Address - Country:US
Mailing Address - Phone:812-793-3582
Mailing Address - Fax:
Practice Address - Street 1:2530 SANDCREST BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201
Practice Address - Country:US
Practice Address - Phone:812-372-3177
Practice Address - Fax:812-372-3692
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-12
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001264A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical