Healthcare Provider Details

I. General information

NPI: 1285064246
Provider Name (Legal Business Name): LACEY CORNELIUSEN, LICSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2013
Last Update Date: 11/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 MAIN ST S STE 301
MINOT ND
58701-3956
US

IV. Provider business mailing address

1310 2ND ST SE
MINOT ND
58701-5912
US

V. Phone/Fax

Practice location:
  • Phone: 406-939-1976
  • Fax:
Mailing address:
  • Phone: 406-939-1976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4558
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. LACEY DAWN CORNELISEN
Title or Position: THERAPIST
Credential: LICSW
Phone: 406-939-1976