Provider Demographics
NPI:1235986340
Name:LACY, KENNETH BART
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:BART
Last Name:LACY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 W CYPRESS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-1703
Mailing Address - Country:US
Mailing Address - Phone:954-683-3463
Mailing Address - Fax:
Practice Address - Street 1:2717 W CYPRESS CREEK RD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-1703
Practice Address - Country:US
Practice Address - Phone:954-683-3463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH24593101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor