Healthcare Provider Details

I. General information

NPI: 1811478936
Provider Name (Legal Business Name): LACEY DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13825 TAPIA AVE
BAYOU LA BATRE AL
36509-2515
US

IV. Provider business mailing address

5750A SOUTHLAND DR
MOBILE AL
36693-3316
US

V. Phone/Fax

Practice location:
  • Phone: 251-824-2310
  • Fax:
Mailing address:
  • Phone: 251-450-2211
  • Fax: 251-662-7297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3909
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: