Provider Demographics
NPI:1144595323
Name:PETERSEN, LACEY K (LCSW)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:K
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:HARPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:510 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-2760
Mailing Address - Country:US
Mailing Address - Phone:307-632-9362
Mailing Address - Fax:307-637-6852
Practice Address - Street 1:510 W 29TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-2760
Practice Address - Country:US
Practice Address - Phone:307-632-9362
Practice Address - Fax:307-637-6852
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW-19421041C0700X
WYLCSW-10461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical