Basic Information
| Provider Information | |||||||||
| NPI: | 1750831806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISE | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | CADC-II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1530 3RD ST STE 111 | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956482501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168840015 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1530 3RD ST STE 111 | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956482501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168840015 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2016 | ||||||||
| LastUpdateDate: | 06/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | A057120520 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.