Basic Information
| Provider Information | |||||||||
| NPI: | 1871819979 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORNELIUSEN | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6301 19TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587038899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018523628 | ||||||||
| FaxNumber: | 7018521190 | ||||||||
| Practice Location | |||||||||
| Address1: | 6301 19TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587038899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018523628 | ||||||||
| FaxNumber: | 7018521190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2010 | ||||||||
| LastUpdateDate: | 12/31/2013 | ||||||||
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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 | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 4558 | ND | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 19337 | 05 | ND | MEDICAID | 74214 | 05 | ND | MEDICAID |