Provider Demographics
NPI:1275193401
Name:BAKKEN, LACEY JO (OTR/L)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:JO
Last Name:BAKKEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:JO
Other - Last Name:BRILZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:5225 23RD AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7927
Mailing Address - Country:US
Mailing Address - Phone:701-417-3400
Mailing Address - Fax:
Practice Address - Street 1:5225 23RD AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7927
Practice Address - Country:US
Practice Address - Phone:701-417-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1650225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1650OtherNDOTA