Provider Demographics
NPI:1366042533
Name:LACY, KATELYN ELIZABETH (OTD)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:ELIZABETH
Last Name:LACY
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 JOSHUA CIR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-9616
Mailing Address - Country:US
Mailing Address - Phone:501-516-7775
Mailing Address - Fax:
Practice Address - Street 1:2201 WILDWOOD AVE
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-5074
Practice Address - Country:US
Practice Address - Phone:501-834-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR3437225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist