Provider Demographics
NPI:1447586813
Name:ABBOTT, LACEY KATHLEEN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:KATHLEEN
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24595 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-3390
Mailing Address - Country:US
Mailing Address - Phone:503-492-6851
Mailing Address - Fax:
Practice Address - Street 1:24595 SE STARK ST
Practice Address - Street 2:
Practice Address - City:TROUTDALE
Practice Address - State:OR
Practice Address - Zip Code:97060-3390
Practice Address - Country:US
Practice Address - Phone:503-492-6851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-20
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10606225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist