Provider Demographics
NPI:1356642656
Name:TUCKER, LACY AMES (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:AMES
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:LACY
Other - Middle Name:AMES
Other - Last Name:BANKSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:103 CANOY LN
Mailing Address - Street 2:SUITE 113
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-3153
Mailing Address - Country:US
Mailing Address - Phone:864-654-2001
Mailing Address - Fax:800-305-7112
Practice Address - Street 1:103 CANOY LN
Practice Address - Street 2:SUITE 113
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-3153
Practice Address - Country:US
Practice Address - Phone:864-654-2001
Practice Address - Fax:800-305-7112
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6081225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist