Provider Demographics
NPI:1821067455
Name:LAWRENCE, VICKIE LEE (PT)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:LEE
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:VICKIE
Other - Middle Name:LEE
Other - Last Name:DIERCKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1069 DELAWARE AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-1400
Mailing Address - Country:US
Mailing Address - Phone:740-382-1734
Mailing Address - Fax:740-387-6918
Practice Address - Street 1:1069 DELAWARE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-1400
Practice Address - Country:US
Practice Address - Phone:740-382-1734
Practice Address - Fax:740-387-6918
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT002795225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4162401Medicare ID - Type Unspecified