Basic Information
| Provider Information | |||||||||
| NPI: | 1154087682 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACOUR | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | KRISTINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 CHINABERRY DR STE 900 | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711112455 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 751 BAYOU PINES EAST DR STE C | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706017196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374333292 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2021 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.