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General NPI Number Information
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NPI Number | 1417624859
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Entity Type | Individual
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Provider Name | LACEY JANE BUCKELEW ASW
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Gender | Female
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Dates
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Enumeration Date | 08/24/2021
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Last Update Date | 07/24/2025
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Provider Practice Location Address
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Address Line | 301 VICTORIA ST
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City | COSTA MESA
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State | CA
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Zip | 92627-1995
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Country | US
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Telephone | 949-574-3367
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Fax | 949-999-6192
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Provider Business Mailing Address
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Address Line | PO BOX 735 1927 HARBOR BLVD.
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City | COSTA MESA
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State | CA
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Zip | 92627
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Country | US
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Telephone | 714-651-1869
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 124851
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License Number State | CA
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