Provider Demographics
NPI:1669018149
Name:ROGERS, KACY ANN (PTA)
Entity Type:Individual
Prefix:
First Name:KACY
Middle Name:ANN
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KACY
Other - Middle Name:ANN
Other - Last Name:LAINHART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:105 MELISSA DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61753-1711
Mailing Address - Country:US
Mailing Address - Phone:309-472-2345
Mailing Address - Fax:
Practice Address - Street 1:105 MELISSA DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:IL
Practice Address - Zip Code:61753-1711
Practice Address - Country:US
Practice Address - Phone:309-472-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004045225200000X
IL160.004045225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant