Provider Demographics
NPI:1922396480
Name:WILCOX, LACEY (DPT)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:WILCOX
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1833 E BISMARCK EXPRESSWAY
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504
Mailing Address - Country:US
Mailing Address - Phone:701-839-5902
Mailing Address - Fax:701-839-5909
Practice Address - Street 1:1833 E BISMARCK EXPY
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-6708
Practice Address - Country:US
Practice Address - Phone:701-323-5222
Practice Address - Fax:701-323-5867
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1640225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist