Healthcare Provider Details

I. General information

NPI: 1528705050
Provider Name (Legal Business Name): JOHN WALTER LACE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 A AVE NE PMR - NEUROPSYCHOLOGY
CEDAR RAPIDS IA
52402
US

IV. Provider business mailing address

1026 A AVE NE
CEDAR RAPIDS IA
52402-5036
US

V. Phone/Fax

Practice location:
  • Phone: 319-369-7211
  • Fax:
Mailing address:
  • Phone: 319-369-7211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number110965
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5000-57
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number110965
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number5000-57
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number126559
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: