Provider Demographics
NPI:1518083120
Name:GLUECKERT, LACEY JEAN (LAC)
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:JEAN
Last Name:GLUECKERT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MISS
Other - First Name:LACEY
Other - Middle Name:JEAN
Other - Last Name:FLECKENSTEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:705 E HIGHLAND DR STE E
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-4494
Mailing Address - Country:US
Mailing Address - Phone:701-770-9743
Mailing Address - Fax:701-572-5410
Practice Address - Street 1:705 E HIGHLAND DR STE E
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-4494
Practice Address - Country:US
Practice Address - Phone:701-770-9743
Practice Address - Fax:701-572-5410
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1577101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)