Provider Demographics
NPI:1871819979
Name:CORNELIUSEN, LACEY D (LICSW)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:D
Last Name:CORNELIUSEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 19TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-8899
Mailing Address - Country:US
Mailing Address - Phone:701-852-3628
Mailing Address - Fax:701-852-1190
Practice Address - Street 1:6301 19TH AVE NW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-8899
Practice Address - Country:US
Practice Address - Phone:701-852-3628
Practice Address - Fax:701-852-1190
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ND45581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19337Medicaid
ND74214Medicaid