MEDICARE: MRS. LACEY LOUGHLIN

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

General Provider Information

NPI Number	:	1366372740
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LACEY LOUGHLIN

Provider Business Mailing Address
First Line	:	814 TYVOLA RD STE 126
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28217-3539
Country	:	US
Telephone Number	:	282-179-8078
Fax Number	:	980-785-1114

Provider Business Practice Location Address
First Line	:	3900 FAYETTEVILLE RD # 100
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27603-3602
Country	:	US
Telephone Number	:	919-827-0560
Fax Number	:

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

Provider Enumeration Date	:	05/19/2026
Last Update Date	:	05/19/2026

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