Healthcare Provider Details

I. General information

NPI: 1487161774
Provider Name (Legal Business Name): MISTY LYNN LACY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 E 7TH ST STE 207
THE DALLES OR
97058-2676
US

IV. Provider business mailing address

419 E 7TH ST STE 207
THE DALLES OR
97058-2676
US

V. Phone/Fax

Practice location:
  • Phone: 541-296-5452
  • Fax: 541-296-1537
Mailing address:
  • Phone: 541-296-5452
  • Fax: 541-296-1537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC8485
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: