Provider Demographics
NPI:1275833345
Name:LEWIS, KACEY JOLENE (PT, MPT, OCS)
Entity Type:Individual
Prefix:MRS
First Name:KACEY
Middle Name:JOLENE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PT, MPT, OCS
Other - Prefix:MISS
Other - First Name:KACEY
Other - Middle Name:JOLENE
Other - Last Name:CRENSHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, MPT, OCS
Mailing Address - Street 1:1016 OCEAN AVE
Mailing Address - Street 2:APT H
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-6480
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1016 OCEAN AVE
Practice Address - Street 2:APT H
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-6480
Practice Address - Country:US
Practice Address - Phone:562-212-7102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-23
Last Update Date:2012-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0000000002251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic