Provider Demographics
NPI:1760222889
Name:JOHNS, LACEY S
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:S
Last Name:JOHNS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8625 BACKWATER DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-8450
Mailing Address - Country:US
Mailing Address - Phone:479-318-2300
Mailing Address - Fax:
Practice Address - Street 1:601 NOBLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5544
Practice Address - Country:US
Practice Address - Phone:260-420-9332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician