Provider Demographics
NPI:1487846960
Name:LACEY, MICHELLE ELAINE (DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELAINE
Last Name:LACEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ELAINE
Other - Last Name:AXELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1917 ABBOTT RD
Mailing Address - Street 2:STE 200
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-3448
Mailing Address - Country:US
Mailing Address - Phone:907-279-4266
Mailing Address - Fax:907-279-4272
Practice Address - Street 1:3051 E PALMER WASILLA HWY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7234
Practice Address - Country:US
Practice Address - Phone:907-279-4266
Practice Address - Fax:907-279-4272
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5439225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT6960Medicaid