Provider Demographics
NPI:1912593831
Name:STONEBRAKER, LACEY N
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:N
Last Name:STONEBRAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:N
Other - Last Name:BACON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-274-4779
Practice Address - Fax:317-948-9806
Is Sole Proprietor?:No
Enumeration Date:2020-12-15
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34008441A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300046024Medicaid