Provider Demographics
NPI:1053679779
Name:LACEY, CHERYL LYNN (LICSW)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:LYNN
Last Name:LACEY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 TOWN FARM RD
Mailing Address - Street 2:
Mailing Address - City:PASCOAG
Mailing Address - State:RI
Mailing Address - Zip Code:02859-2405
Mailing Address - Country:US
Mailing Address - Phone:401-862-7850
Mailing Address - Fax:
Practice Address - Street 1:300 TOLL GATE RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-4416
Practice Address - Country:US
Practice Address - Phone:401-862-7850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICSW014841041C0700X
MA2185581041C0700X
RIISW024131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIGH57134Medicaid