Provider Demographics
NPI:1518671437
Name:LEE, LACI A (MT)
Entity Type:Individual
Prefix:
First Name:LACI
Middle Name:A
Last Name:LEE
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 SAVANNAH AVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458
Mailing Address - Country:US
Mailing Address - Phone:912-243-9200
Mailing Address - Fax:912-243-9207
Practice Address - Street 1:116 SAVANNAH AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458
Practice Address - Country:US
Practice Address - Phone:912-243-9200
Practice Address - Fax:912-243-9207
Is Sole Proprietor?:No
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT013865225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist