Provider Demographics
NPI:1104016682
Name:GRACE, LACEY ANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:ANN
Last Name:GRACE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:NH
Mailing Address - Zip Code:03603-4716
Mailing Address - Country:US
Mailing Address - Phone:603-826-5702
Mailing Address - Fax:
Practice Address - Street 1:24 OLD ETNA RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1937
Practice Address - Country:US
Practice Address - Phone:603-442-4207
Practice Address - Fax:603-442-4250
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0845225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant