Provider Demographics
NPI:1770684995
Name:JOHNSON, LACEY BROOKE (MHS, OTR/L)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:BROOKE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MHS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 TIARA CT
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29625-2770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 E GREENVILLE ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-2004
Practice Address - Country:US
Practice Address - Phone:864-226-8356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2993225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist