MEDICARE: OLIVIA LACEWELL

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	106S00000X	Behavior Technician
2	106E00000X	Assistant Behavior Analyst

General Provider Information

NPI Number	:	1235645680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA LACEWELL

Provider Business Mailing Address
First Line	:	904 MOUNTAIN LION CIR STE 500
Second Line	:
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548-5725
Country	:	US
Telephone Number	:	800-345-0448
Fax Number	:

Provider Business Practice Location Address
First Line	:	5446 N ACADEMY BLVD STE 105
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3668
Country	:	US
Telephone Number	:	719-598-5555
Fax Number	:

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

Provider Enumeration Date	:	12/21/2017
Last Update Date	:	04/21/2023

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Directions to “ OLIVIA LACEWELL ” Practice Location

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