Provider Demographics
NPI:1346907383
Name:COOPER, LACEY (PTA)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:COOPER
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 1:15385 W FILLMORE ST UNIT 35
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-4182
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15385 W FILLMORE ST UNIT 35
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-4182
Practice Address - Country:US
Practice Address - Phone:623-692-9917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPTA-013960208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation