MEDICARE: LACEY FOX

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist		MI

General Provider Information

NPI Number	:	1114771144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACEY FOX

Provider Business Mailing Address
First Line	:	9612 E OLIVE RD
Second Line	:
City	:	WHEELER
State	:	MI
Zip	:	48662-9745
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1234 E BROOMFIELD ST
Second Line	:
City	:	MT PLEASANT
State	:	MI
Zip	:	48858-4491
Country	:	US
Telephone Number	:	989-817-7915
Fax Number	:	989-423-0630

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2024
Last Update Date	:	04/16/2024

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Directions to “ LACEY FOX ” Practice Location

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