Provider Demographics
NPI:1093325706
Name:LEICHTNAM, LACEY A (MA, LPC, ACT, QMHP)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:A
Last Name:LEICHTNAM
Suffix:
Gender:F
Credentials:MA, LPC, ACT, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 S LOUISE AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-3124
Mailing Address - Country:US
Mailing Address - Phone:605-334-7713
Mailing Address - Fax:
Practice Address - Street 1:4300 S LOUISE AVE STE 201
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-3124
Practice Address - Country:US
Practice Address - Phone:605-334-7713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD20388101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health