Provider Demographics
NPI:1962075655
Name:HORN, LAECIE LAREE (FOUNDER)
Entity type:Individual
Prefix:
First Name:LAECIE
Middle Name:LAREE
Last Name:HORN
Suffix:
Gender:F
Credentials:FOUNDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11613 S SUNBURN CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-5523
Mailing Address - Country:US
Mailing Address - Phone:801-674-6367
Mailing Address - Fax:
Practice Address - Street 1:11613 S SUNBURN CIR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-5523
Practice Address - Country:US
Practice Address - Phone:801-674-6367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2024-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT215419110216405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty