Provider Demographics
NPI:1154830677
Name:WISE, LACEY (PT)
Entity Type:Individual
Prefix:MS
First Name:LACEY
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 S MARKET BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-4100
Mailing Address - Country:US
Mailing Address - Phone:360-996-4410
Mailing Address - Fax:360-996-4466
Practice Address - Street 1:1316 MT SAINT HELENS WAY SE
Practice Address - Street 2:SUITE B
Practice Address - City:CASTLE ROCK
Practice Address - State:WA
Practice Address - Zip Code:98611
Practice Address - Country:US
Practice Address - Phone:360-557-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61342050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist