Doctor Name: | MRS. LACEY JO ANDERSON |
NPI Number: | 1861872558 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | |
License Number: | 180 |
Business Practice Address: | 25224 W. Eames St. Channahon, IL - 604103102 |
Business Phone Number: | 8154678181 |
Business Fax Number: | |
Mailing Address: | 25224 W. Eames St., CHANNAHON |
State: | IL |
Postal Code: | 604103102 |
Phone Number: | 8154678181 |
Fax Number: | |
NPI Enumeration Date: | 06/08/2015 |
NPI Last Update Date: | 06/08/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YP2500X |
License Number: | 180 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IL |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Professional |
Taxonomy Definition: |