Healthcare Provider Details

I. General information

NPI: 1952223356
Provider Name (Legal Business Name): LACEY NICOLE BEVAN L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LACEY NICOLE BINGER LMT

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E CENTER ST SUITE F
POCATELLO ID
83201-5737
US

IV. Provider business mailing address

1792 E PRICE RD
MCCAMMON ID
83250-1610
US

V. Phone/Fax

Practice location:
  • Phone: 208-637-9940
  • Fax:
Mailing address:
  • Phone: 208-637-9940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMASG-1967
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: