Provider Demographics
NPI:1013507201
Name:NOWICKI, LACY (OTR/L)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:NOWICKI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 W TYVOLA RD STE 350
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-4574
Mailing Address - Country:US
Mailing Address - Phone:419-221-3004
Mailing Address - Fax:
Practice Address - Street 1:10222 74TH ST STE 211
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-6810
Practice Address - Country:US
Practice Address - Phone:262-925-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI719-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI7219-26Medicaid