Healthcare Provider Details

I. General information

NPI: 1144595323
Provider Name (Legal Business Name): LACEY K PETERSEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LACEY HARPER LCSW

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 09/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 W 29TH ST
CHEYENNE WY
82001-2760
US

IV. Provider business mailing address

510 W 29TH ST
CHEYENNE WY
82001-2760
US

V. Phone/Fax

Practice location:
  • Phone: 307-632-9362
  • Fax: 307-637-6852
Mailing address:
  • Phone: 307-632-9362
  • Fax: 307-637-6852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW-1942
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-1046
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: