Healthcare Provider Details

I. General information

NPI: 1821116294
Provider Name (Legal Business Name): LACY KEITH M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 05/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E 1ST ST
PORTALES NM
88130-5914
US

IV. Provider business mailing address

1525 S AVENUE C
PORTALES NM
88130-6819
US

V. Phone/Fax

Practice location:
  • Phone: 575-359-1221
  • Fax:
Mailing address:
  • Phone: 575-309-3868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0151121
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number156141
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: