Provider Demographics
NPI:1568823201
Name:LEAF, LACEY JEAN (OTA)
Entity Type:Individual
Prefix:MS
First Name:LACEY
Middle Name:JEAN
Last Name:LEAF
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 RAMIREZ ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-4334
Mailing Address - Country:US
Mailing Address - Phone:530-742-7311
Mailing Address - Fax:
Practice Address - Street 1:1617 RAMIREZ ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-4334
Practice Address - Country:US
Practice Address - Phone:530-742-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2002224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant