Provider Demographics
NPI:1639510282
Name:ELLIS, LACEY LORAL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:LORAL
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2685 PELHAM PKWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:PELHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35124-1354
Mailing Address - Country:US
Mailing Address - Phone:205-621-6503
Mailing Address - Fax:205-621-6507
Practice Address - Street 1:2685 PELHAM PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:PELHAM
Practice Address - State:AL
Practice Address - Zip Code:35124-1354
Practice Address - Country:US
Practice Address - Phone:205-621-6503
Practice Address - Fax:205-621-6507
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT267202251P0200X
ALPTH68022251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics