Provider Demographics
NPI:1346483823
Name:BELLAR, LACY D (PTA)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:D
Last Name:BELLAR
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:PO BOX 4
Mailing Address - Street 2:
Mailing Address - City:LENAPAH
Mailing Address - State:OK
Mailing Address - Zip Code:74042-0004
Mailing Address - Country:US
Mailing Address - Phone:918-244-5420
Mailing Address - Fax:
Practice Address - Street 1:6024 CORNELL DR
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-8929
Practice Address - Country:US
Practice Address - Phone:918-244-5420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1402029225200000X
OK1436225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant