| Doctor Name: | LACY WEIDERT |
| NPI Number: | 1003211400 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LICSW |
| License Number: | 20219 |
| Business Practice Address: | 13045 Falcon Dr Ste 100 Baxter, MN - 564254201 |
| Business Phone Number: | 2188299307 |
| Business Fax Number: | 2188297649 |
| Mailing Address: | 1900 Silver Lake Rd Nw, Suite 110 NEW BRIGHTON |
| State: | MN |
| Postal Code: | 551121786 |
| Phone Number: | 6513791718 |
| Fax Number: | 6513791738 |
| NPI Enumeration Date: | 10/28/2014 |
| NPI Last Update Date: | 03/14/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 20219 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |