Provider Demographics
NPI:1356649909
Name:LACEY MACKENZIE COUNSELING
Entity Type:Organization
Organization Name:LACEY MACKENZIE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:LACEY
Authorized Official - Middle Name:JILL
Authorized Official - Last Name:MACKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:208-739-0982
Mailing Address - Street 1:PO BOX 173
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-0173
Mailing Address - Country:US
Mailing Address - Phone:208-739-0982
Mailing Address - Fax:
Practice Address - Street 1:1509 N WHITLEY DR
Practice Address - Street 2:SUITE 11
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2259
Practice Address - Country:US
Practice Address - Phone:208-739-0982
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-07
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-4348251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health