=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366323115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LACEY PSYCHOTHERAPY, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2025
-----------------------------------------------------
Last Update Date | 09/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 LONG LAKE RD STE 320
-----------------------------------------------------
City | NEW BRIGHTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55112-6439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-482-9361
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 LONG LAKE RD STE 320
-----------------------------------------------------
City | NEW BRIGHTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55112-6439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-482-9361
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | ETHAN K LACEY
-----------------------------------------------------
Credential | MA, LPCC
-----------------------------------------------------
Telephone | 651-482-9361
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------