MEDICARE: CARLY LACELLE

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	103TC1900X	Counseling Psychologist	6301017883	MI
2	103T00000X	Psychologist	6361007651	MI

General Provider Information

NPI Number	:	1790334829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY LACELLE

Provider Business Mailing Address
First Line	:	1611 W CENTRE AVE STE 108
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024-5344
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1611 W CENTRE AVE STE 108
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024-5344
Country	:	US
Telephone Number	:	269-366-8858
Fax Number	:

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

Provider Enumeration Date	:	09/11/2019
Last Update Date	:	05/06/2026

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Directions to “ CARLY LACELLE ” Practice Location

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