Provider Demographics
NPI:1689237877
Name:LACY, GABLE HARVEY
Entity Type:Individual
Prefix:
First Name:GABLE
Middle Name:HARVEY
Last Name:LACY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 W SIMPSON RD
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-8082
Mailing Address - Country:US
Mailing Address - Phone:360-490-6369
Mailing Address - Fax:
Practice Address - Street 1:710 SE CHINOOK DR APT K50
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-4822
Practice Address - Country:US
Practice Address - Phone:360-490-6369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer