Healthcare Provider Details

I. General information

NPI: 1740790856
Provider Name (Legal Business Name): SCOTT LACY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 CALLE PORTAL STE C240
SIERRA VISTA AZ
85635-2986
US

IV. Provider business mailing address

1205 N F AVE
DOUGLAS AZ
85607-1920
US

V. Phone/Fax

Practice location:
  • Phone: 520-515-8669
  • Fax: 520-515-8688
Mailing address:
  • Phone: 520-364-1429
  • Fax: 520-515-8690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA1807098
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA1807098
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-23305
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: