Provider Demographics
NPI:1124216213
Name:PETERSON, LACEY MARIE (CPTA)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:249 E 1ST ST
Mailing Address - City:PARKER
Mailing Address - State:SD
Mailing Address - Zip Code:57053
Mailing Address - Country:US
Mailing Address - Phone:605-297-2442
Mailing Address - Fax:
Practice Address - Street 1:1807 PASO ROBLE WAY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716-2418
Practice Address - Country:US
Practice Address - Phone:605-267-0314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0174225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant