Healthcare Provider Details

I. General information

NPI: 1407360951
Provider Name (Legal Business Name): LACEY ANN HANCOCK LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2017
Last Update Date: 09/12/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 E FORT UNION BLVD STE 104
MIDVALE UT
84047
US

IV. Provider business mailing address

613 E FORT UNION BLVD STE 104
MIDVALE UT
84047-5531
US

V. Phone/Fax

Practice location:
  • Phone: 801-984-1717
  • Fax: 801-984-1720
Mailing address:
  • Phone: 801-984-1717
  • Fax: 801-984-1720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8756352-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: