Healthcare Provider Details

I. General information

NPI: 1366372740
Provider Name (Legal Business Name): MRS. LACEY LOUGHLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 FAYETTEVILLE RD # 100
RALEIGH NC
27603-3602
US

IV. Provider business mailing address

814 TYVOLA RD STE 126
CHARLOTTE NC
28217-3539
US

V. Phone/Fax

Practice location:
  • Phone: 919-827-0560
  • Fax:
Mailing address:
  • Phone: 282-179-8078
  • Fax: 980-785-1114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: