Provider Demographics
NPI:1861813271
Name:LACEY CORNELIUSEN, LICSW, LLC
Entity Type:Organization
Organization Name:LACEY CORNELIUSEN, LICSW, LLC
Other - Org Name:SERENITY HEALTH SOLUTIONS
Other - Org Type:Other Name
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LACEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:CORNELIUSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:701-838-1558
Mailing Address - Street 1:315 MAIN ST S
Mailing Address - Street 2:STE 301
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-3956
Mailing Address - Country:US
Mailing Address - Phone:701-838-1558
Mailing Address - Fax:701-852-0402
Practice Address - Street 1:315 MAIN ST S
Practice Address - Street 2:STE 301
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3956
Practice Address - Country:US
Practice Address - Phone:701-838-1558
Practice Address - Fax:701-852-0402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND45581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19337Medicaid