Provider Demographics
NPI:1134701899
Name:HOUDEK, LACEY NICOLE (LICSW)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:NICOLE
Last Name:HOUDEK
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:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-1166
Mailing Address - Fax:
Practice Address - Street 1:2925 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1321
Practice Address - Country:US
Practice Address - Phone:866-603-0016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN276261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical