Provider Demographics
NPI:1770251621
Name:WISNIEWSKA, LACEY CASSANDRA
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:CASSANDRA
Last Name:WISNIEWSKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:CASSANDRA
Other - Last Name:STEWARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 RAILROAD AVE S
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-5934
Mailing Address - Country:US
Mailing Address - Phone:844-623-9675
Mailing Address - Fax:
Practice Address - Street 1:420 PONTIUS AVE N APT 610
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-5690
Practice Address - Country:US
Practice Address - Phone:253-284-6120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA390200000X
WAMC61429317101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program