Healthcare Provider Details

I. General information

NPI: 1336868280
Provider Name (Legal Business Name): DEREK CHRISTOPHER LACY LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2022
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 N MAIN ST
PROVIDENCE RI
02904-5762
US

IV. Provider business mailing address

530 N MAIN ST
PROVIDENCE RI
02904-5762
US

V. Phone/Fax

Practice location:
  • Phone: 401-455-6528
  • Fax:
Mailing address:
  • Phone: 401-276-6151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC01887
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: