MEDICARE: LACY RENAE BANGERT LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	23036	AZ
2	101YP2500X	Professional Counselor	1675	WY
3	101YP2500X	Professional Counselor	C8769	OR
4	101YP2500X	Professional Counselor	0017704	CO

General Provider Information

NPI Number	:	1215561915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACY RENAE BANGERT LPC

Provider Business Mailing Address
First Line	:	15150 W PARK PL
Second Line	:
City	:	GOODYEAR
State	:	AZ
Zip	:	85395-2385
Country	:	US
Telephone Number	:	307-630-0511
Fax Number	:

Provider Business Practice Location Address
First Line	:	17284 W MOHAVE ST
Second Line	:
City	:	GOODYEAR
State	:	AZ
Zip	:	85338-1788
Country	:	US
Telephone Number	:	307-630-0511
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2020
Last Update Date	:	06/05/2026

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