Provider Demographics
NPI:1831681428
Name:INGRID J LACEY, LLC
Entity type:Organization
Organization Name:INGRID J LACEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:JENNIFER
Authorized Official - Last Name:LACEY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, BC-DMT, GLCMA
Authorized Official - Phone:415-913-8831
Mailing Address - Street 1:2156 CAVANAUGH AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-2706
Mailing Address - Country:US
Mailing Address - Phone:415-913-8831
Mailing Address - Fax:
Practice Address - Street 1:1799 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4005
Practice Address - Country:US
Practice Address - Phone:404-490-0664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008680101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty