Provider Demographics
NPI:1750431532
Name:LACY, BETTY G (MD)
Entity type:Individual
Prefix:DR
First Name:BETTY
Middle Name:G
Last Name:LACY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 HELEN AVENUE
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5825
Mailing Address - Country:US
Mailing Address - Phone:707-462-8783
Mailing Address - Fax:707-462-8783
Practice Address - Street 1:932 HELEN AVENUE
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5825
Practice Address - Country:US
Practice Address - Phone:707-462-8783
Practice Address - Fax:707-462-8783
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG671122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G67112Medicare PIN
E25062Medicare UPIN
CA00G671Medicare ID - Type Unspecified
CAE25062Medicare UPIN