Provider Demographics
NPI:1053625970
Name:LACY, MARTHA JANET (QMHA)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:JANET
Last Name:LACY
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:JAN
Other - Middle Name:
Other - Last Name:LACY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:QMHA
Mailing Address - Street 1:12901 SE 97TH AVE STE 340
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-7903
Mailing Address - Country:US
Mailing Address - Phone:503-303-2879
Mailing Address - Fax:
Practice Address - Street 1:12901 SE 97TH AVE STE 340
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-7903
Practice Address - Country:US
Practice Address - Phone:503-434-7462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-03
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health