Provider Demographics
NPI:1982115671
Name:WUTHRICH, LACEY JANE (LMSW)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:JANE
Last Name:WUTHRICH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 E CLARK ST STE 330
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3357
Mailing Address - Country:US
Mailing Address - Phone:208-233-5433
Mailing Address - Fax:877-284-2783
Practice Address - Street 1:1777 E CLARK ST STE 330
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3357
Practice Address - Country:US
Practice Address - Phone:208-233-5433
Practice Address - Fax:877-284-2783
Is Sole Proprietor?:No
Enumeration Date:2017-10-20
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID$$$$$$$$$Medicaid