Provider Demographics
NPI:1265923304
Name:LACEY, AMBER LYNN (CDCA)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:LYNN
Last Name:LACEY
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13129 BETHESDA RD
Mailing Address - Street 2:
Mailing Address - City:HANOVERTON
Mailing Address - State:OH
Mailing Address - Zip Code:44423-9753
Mailing Address - Country:US
Mailing Address - Phone:330-341-2145
Mailing Address - Fax:
Practice Address - Street 1:15898 SAINT CLAIR AVE STE 1
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-9122
Practice Address - Country:US
Practice Address - Phone:330-932-0157
Practice Address - Fax:330-932-0869
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA164344101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)