Provider Demographics
NPI:1710493291
Name:MAUDLIN, LACEY TAYLOR
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:TAYLOR
Last Name:MAUDLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 SW 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-4371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 SW 12TH AVE
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-4371
Practice Address - Country:US
Practice Address - Phone:360-666-7722
Practice Address - Fax:360-666-3388
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60607967225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist