Provider Demographics
NPI:1982939138
Name:FOURONG, LACY RAE (MS, LMFT)
Entity Type:Individual
Prefix:MS
First Name:LACY
Middle Name:RAE
Last Name:FOURONG
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 W BLAINE ST STE D
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-3940
Mailing Address - Country:US
Mailing Address - Phone:951-223-8131
Mailing Address - Fax:
Practice Address - Street 1:4199 FLAT ROCK DR STE 130L
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-7129
Practice Address - Country:US
Practice Address - Phone:951-223-8131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2022-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60910106H00000X
CA87955106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist