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General NPI Number Information
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NPI Number | 1821116294
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Entity Type | Individual
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Provider Name | LACY KEITH M.A.
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Gender | Female
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Dates
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Enumeration Date | 03/26/2007
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Last Update Date | 05/06/2013
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Provider Practice Location Address
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Address Line | 300 E 1ST ST
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City | PORTALES
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State | NM
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Zip | 88130-5914
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Country | US
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Telephone | 575-359-1221
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Fax |
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Provider Business Mailing Address
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Address Line | 1525 S AVENUE C
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City | PORTALES
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State | NM
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Zip | 88130-6819
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Country | US
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Telephone | 575-309-3868
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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 | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | T-0151121
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License Number State | NM
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 156141
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License Number State | NM
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