Healthcare Provider Details

I. General information

NPI: 1528982816
Provider Name (Legal Business Name): LACEY BUZZARD CPSST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LACEY MICKELSON

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1126 S GOLD ST
CENTRALIA WA
98531-3714
US

IV. Provider business mailing address

PO BOX 2394
LONGVIEW WA
98632-8455
US

V. Phone/Fax

Practice location:
  • Phone: 360-807-4929
  • Fax: 844-612-6673
Mailing address:
  • Phone: 360-200-5419
  • Fax: 844-612-6673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCG70161196
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberPE70140469
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: