Healthcare Provider Details

I. General information

NPI: 1225950595
Provider Name (Legal Business Name): LACIE CLARK CAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 MAXWELL ST
COLORADO SPRINGS CO
80906-5554
US

IV. Provider business mailing address

5355 TURQUOISE DR
COLORADO SPRINGS CO
80918-4910
US

V. Phone/Fax

Practice location:
  • Phone: 719-203-6550
  • Fax:
Mailing address:
  • Phone: 719-203-6550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACA0008599
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: