Healthcare Provider Details

I. General information

NPI: 1215248877
Provider Name (Legal Business Name): KIMBERLY GAY LACY M.A. L.M.H.C.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9450 ETHAN WADE WAY SE
SNOQUALMIE WA
98065-9520
US

IV. Provider business mailing address

PO BOX 969
SNOQUALMIE WA
98065-0969
US

V. Phone/Fax

Practice location:
  • Phone: 425-831-2100
  • Fax: 425-831-2112
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC 60117580
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: