Provider Demographics
NPI:1073703690
Name:KONICKSON, LACEY LYNN OPPERUD (MOT)
Entity type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:LYNN OPPERUD
Last Name:KONICKSON
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:MISS
Other - First Name:LACEY
Other - Middle Name:LYNN OPPERUD
Other - Last Name:PAHLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-9419
Mailing Address - Fax:701-780-1942
Practice Address - Street 1:3001 SANFORD PKWY
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-2700
Practice Address - Country:US
Practice Address - Phone:701-780-5000
Practice Address - Fax:701-780-1942
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103465225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist