Basic Information
| Provider Information | |||||||||
| NPI: | 1356649909 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LACEY MACKENZIE COUNSELING | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 173 | ||||||||
| Address2: | |||||||||
| City: | WEISER | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836720173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087390982 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1509 N WHITLEY DR | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | FRUITLAND | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836192259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087390982 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2011 | ||||||||
| LastUpdateDate: | 03/07/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MACKENZIE | ||||||||
| AuthorizedOfficialFirstName: | LACEY | ||||||||
| AuthorizedOfficialMiddleName: | JILL | ||||||||
| AuthorizedOfficialTitleorPosition: | MENTAL HEALTH COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 2087390982 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LPC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | LPC-4348 | ID | Y | Agencies | Community/Behavioral Health |
No ID Information.