Provider Demographics
NPI:1609109446
Name:LACY, CHRISTOPHER J (PTA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:J
Last Name:LACY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 W NEWBERRY RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-2245
Mailing Address - Country:US
Mailing Address - Phone:352-336-6000
Mailing Address - Fax:352-332-0799
Practice Address - Street 1:146 SW ORTHOPEDIC CT
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32024-0672
Practice Address - Country:US
Practice Address - Phone:386-719-5100
Practice Address - Fax:386-719-5101
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 21841225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA 21841OtherPTA LICENSE