Provider Demographics
NPI:1407832512
Name:GERHARDSON, LACIE MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:LACIE
Middle Name:MARIE
Last Name:GERHARDSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:LACIE
Other - Middle Name:MARIE
Other - Last Name:MOCKROS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:3333 W DIVISION ST STE 122A
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4549
Mailing Address - Country:US
Mailing Address - Phone:320-281-5243
Mailing Address - Fax:320-281-5243
Practice Address - Street 1:3333 W DIVISION ST
Practice Address - Street 2:STE 122A
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4549
Practice Address - Country:US
Practice Address - Phone:320-281-5243
Practice Address - Fax:320-281-0093
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4483111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN001J9OtherHSM ELECT
MN663405OtherCHIROCARE
MN774S0MOOtherBCBS
MN350003002OtherMEDICARE RAIL ROAD
MN706160900Medicaid
MN663405OtherCHIROCARE
MN350003002Medicare ID - Type Unspecified