Healthcare Provider Details

I. General information

NPI: 1982533295
Provider Name (Legal Business Name): LACY RAE KAUSHAGEN DSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 ADAMS BLVD
SILVER BAY MN
55614-1326
US

IV. Provider business mailing address

45 ADAMS BLVD
SILVER BAY MN
55614-1326
US

V. Phone/Fax

Practice location:
  • Phone: 218-213-2708
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number137304120250223
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: