Individual
LACEY D CORNELIUSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LICSW
Contact information
Practice address
6301 19TH AVE NW, MINOT, ND 58703-8899
(701) 852-3628
(701) 852-1190
Mailing address
6301 19TH AVE NW, MINOT, ND 58703-8899
(701) 852-3628
(701) 852-1190
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
—
—
1041C0700X
Clinical Social Worker
4558
ND
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
19337
—
ND
05
—
74214
—
ND
Enumeration date
04/14/2010
Last updated
12/31/2013
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