Provider Demographics
NPI:1841347911
Name:HALLECK, LACEY MARIE (LMP)
Entity type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:MARIE
Last Name:HALLECK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2739 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2046
Mailing Address - Country:US
Mailing Address - Phone:360-740-9714
Mailing Address - Fax:360-740-4879
Practice Address - Street 1:151 N MARKET BLVD STE B
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2677
Practice Address - Country:US
Practice Address - Phone:360-740-9714
Practice Address - Fax:360-740-4879
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021920225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist