Provider Demographics
NPI:1396826806
Name:LAHEY, LACEY M (PT)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:M
Last Name:LAHEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:M
Other - Last Name:HARDESTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:673 SMOKERISE BLVD
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-3383
Mailing Address - Country:US
Mailing Address - Phone:602-402-6502
Mailing Address - Fax:
Practice Address - Street 1:2629 W STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-4878
Practice Address - Country:US
Practice Address - Phone:407-774-1716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL27188225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4920680001Medicare NSC
AZ76390Medicare PIN