Provider Demographics
NPI:1811541444
Name:LUBENOW, LACEY JORDAN HUNTINGTON (MOTR/L)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:JORDAN HUNTINGTON
Last Name:LUBENOW
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:JORDAN
Other - Last Name:HUNTINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOTR/L
Mailing Address - Street 1:4370 GLENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-6370
Mailing Address - Country:US
Mailing Address - Phone:208-406-8745
Mailing Address - Fax:
Practice Address - Street 1:2020 GILKERSON DR
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-2558
Practice Address - Country:US
Practice Address - Phone:406-587-2755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTOTP-OT-LIC-6882225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics