Healthcare Provider Details

I. General information

NPI: 1346166055
Provider Name (Legal Business Name): LACEY CONNOR LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 22ND AVE
LEWISTON ID
83501-3812
US

IV. Provider business mailing address

419 22ND AVE
LEWISTON ID
83501-3812
US

V. Phone/Fax

Practice location:
  • Phone: 208-816-6078
  • Fax:
Mailing address:
  • Phone: 208-816-6078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number9421139
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: