Healthcare Provider Details

I. General information

NPI: 1992139661
Provider Name (Legal Business Name): LACEY GALE LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 NICOLLET AVE SOUTH WASHBURN CENTER FOR CHILDREN
MINNEAPOLIS MN
55404
US

IV. Provider business mailing address

2430 NICOLLET AVE SOUTH WASHBURN CENTER FOR CHILDREN
MINNEAPOLIS MN
55404
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-1454
  • Fax: 612-871-1505
Mailing address:
  • Phone: 612-871-1454
  • Fax: 612-871-1505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17533
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: