Provider Demographics
NPI:1427642511
Name:SOTO, LACEY LYNN (LICSW)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:LYNN
Last Name:SOTO
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 1:238 STONE CREEK DR APT 310
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-6992
Mailing Address - Country:US
Mailing Address - Phone:218-204-1955
Mailing Address - Fax:
Practice Address - Street 1:MAIN AVE
Practice Address - Street 2:
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671-5650
Practice Address - Country:US
Practice Address - Phone:218-204-1955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN259181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical