Provider Demographics
NPI:1043618580
Name:BUCHHOLTZ, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:BUCHHOLTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:WI
Mailing Address - Zip Code:54722-9085
Mailing Address - Country:US
Mailing Address - Phone:715-286-2488
Mailing Address - Fax:
Practice Address - Street 1:708 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:WI
Practice Address - Zip Code:54722-9085
Practice Address - Country:US
Practice Address - Phone:715-286-2488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-16
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2212-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant