Basic Information
| Provider Information | |||||||||
| NPI: | 1447480215 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACKENZIE | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | JILL | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1233 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | WEISER | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836721533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087390982 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1219 SW 4TH AVE UNIT 1 | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 979144500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418892668 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2009 | ||||||||
| LastUpdateDate: | 07/15/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LPC- 4348 | ID | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.