Provider Demographics
NPI:1639370091
Name:LACY, GAYNA GEORGETTE (DPT)
Entity Type:Individual
Prefix:
First Name:GAYNA
Middle Name:GEORGETTE
Last Name:LACY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:GAYNA
Other - Middle Name:THOMAS
Other - Last Name:LACY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4058
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-4058
Mailing Address - Country:US
Mailing Address - Phone:410-315-9080
Mailing Address - Fax:
Practice Address - Street 1:13946 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5000
Practice Address - Country:US
Practice Address - Phone:301-498-2212
Practice Address - Fax:301-498-2213
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22170225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCF8710017OtherCAREFIRST BLUE CROSS BLUE SHIELD
MD22170OtherPT LICENSE