Healthcare Provider Details

I. General information

NPI: 1780997163
Provider Name (Legal Business Name): MS. LACIE A LAFFERTY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 01/20/2026
Certification Date: 01/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12797 3RD ST
YUCAIPA CA
92399-4544
US

IV. Provider business mailing address

12797 3RD ST
YUCAIPA CA
92399-4544
US

V. Phone/Fax

Practice location:
  • Phone: 909-797-0174
  • Fax:
Mailing address:
  • Phone: 909-797-0174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSPA508
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: