Provider Demographics
NPI:1609132786
Name:OTT, LACIE (PTA)
Entity Type:Individual
Prefix:
First Name:LACIE
Middle Name:
Last Name:OTT
Suffix:
Gender:F
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:FILE 50469
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0469
Mailing Address - Country:US
Mailing Address - Phone:530-778-0200
Mailing Address - Fax:530-778-0200
Practice Address - Street 1:751 OLD RICHARDSON HWY
Practice Address - Street 2:SUITE 202
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7813
Practice Address - Country:US
Practice Address - Phone:907-455-4401
Practice Address - Fax:907-455-4402
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2392225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK2392OtherPTA LICENSE #