Provider Demographics
NPI:1629100110
Name:LACY, ANGELA M (OTR)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:M
Last Name:LACY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MRS
Other - First Name:ANGELA
Other - Middle Name:M
Other - Last Name:BURCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:6658 E 10TH STREET
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219
Mailing Address - Country:US
Mailing Address - Phone:317-840-1077
Mailing Address - Fax:317-359-3421
Practice Address - Street 1:6658 E 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3416
Practice Address - Country:US
Practice Address - Phone:317-840-1077
Practice Address - Fax:317-359-3421
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31001390A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200172910BMedicaid
IN200703040AOtherFIRST STEPS PROVIDER #