Provider Demographics
NPI:1376804526
Name:GENGENBACHER, LACEE ANN GEORGE (MS)
Entity Type:Individual
Prefix:
First Name:LACEE
Middle Name:ANN GEORGE
Last Name:GENGENBACHER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 MICHAEL GROVE AVE APT A
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-3682
Mailing Address - Country:US
Mailing Address - Phone:406-422-7678
Mailing Address - Fax:
Practice Address - Street 1:1811 W KOCH ST
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-4127
Practice Address - Country:US
Practice Address - Phone:406-587-1181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health