Provider Demographics
NPI:1447981519
Name:MOORE, LACEY MICHELLE (RBT)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:MICHELLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:MICHELLE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RBT
Mailing Address - Street 1:2852 W 6000 S
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-1022
Mailing Address - Country:US
Mailing Address - Phone:318-751-3122
Mailing Address - Fax:
Practice Address - Street 1:7220 W JEFFERSON AVE STE 100
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80235-2015
Practice Address - Country:US
Practice Address - Phone:720-474-4809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician