Provider Demographics
NPI:1508129396
Name:GEBKE, LACEY ANN (LIMITED PERMIT)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:ANN
Last Name:GEBKE
Suffix:
Gender:F
Credentials:LIMITED PERMIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10560 OLD OLIVE STREET RD
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5916
Mailing Address - Country:US
Mailing Address - Phone:314-567-4707
Mailing Address - Fax:314-567-4505
Practice Address - Street 1:10560 OLD OLIVE STREET RD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-5916
Practice Address - Country:US
Practice Address - Phone:314-567-4707
Practice Address - Fax:314-567-4505
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012017942225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist