Provider Demographics
NPI:1023133022
Name:LACE, MICHAEL ALBIN (PSYD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALBIN
Last Name:LACE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:2141 ALTOONA AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701
Practice Address - Country:US
Practice Address - Phone:715-552-7350
Practice Address - Fax:715-878-9075
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33333103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39365600Medicaid
WI39365600Medicaid