Provider Demographics
NPI:1487214391
Name:PHILLIPS, LACY RAE (PTA)
Entity Type:Individual
Prefix:MISS
First Name:LACY
Middle Name:RAE
Last Name:PHILLIPS
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 1:4733 S RANCH CIR
Mailing Address - Street 2:
Mailing Address - City:BLAIR
Mailing Address - State:NE
Mailing Address - Zip Code:68008-6436
Mailing Address - Country:US
Mailing Address - Phone:712-314-1681
Mailing Address - Fax:
Practice Address - Street 1:4102 WOOLWORTH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-1851
Practice Address - Country:US
Practice Address - Phone:402-444-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11062251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics