MEDICARE: ANDREA LEIGH LACY LCDC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCDC 2700	TX

General Provider Information

NPI Number	:	1386935369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA LEIGH LACY LCDC

Provider Business Mailing Address
First Line	:	918 WEST NOLANA LOOP
Second Line	:
City	:	PHARR
State	:	TX
Zip	:	78577
Country	:	US
Telephone Number	:	956-502-5526
Fax Number	:	956-502-5528

Provider Business Practice Location Address
First Line	:	918 W NOLANA LOOP
Second Line	:
City	:	PHARR
State	:	TX
Zip	:	78577-8340
Country	:	US
Telephone Number	:	956-502-5526
Fax Number	:	956-502-5528

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

Provider Enumeration Date	:	04/26/2011
Last Update Date	:	04/26/2011

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