Healthcare Provider Details

I. General information

NPI: 1790334829
Provider Name (Legal Business Name): CARLY LACELLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 W CENTRE AVE STE 108
PORTAGE MI
49024-5344
US

IV. Provider business mailing address

1611 W CENTRE AVE STE 108
PORTAGE MI
49024-5344
US

V. Phone/Fax

Practice location:
  • Phone: 269-366-8858
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301017883
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6361007651
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: