Provider Demographics
NPI:1013792795
Name:WOODARD, LACEY MARIE
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:MARIE
Last Name:WOODARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:MARIE
Other - Last Name:WOODARD-EMRO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1213 FOGGY BOTTOM RD
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:OK
Mailing Address - Zip Code:74873-1630
Mailing Address - Country:US
Mailing Address - Phone:940-704-5169
Mailing Address - Fax:
Practice Address - Street 1:1400 SE 4TH ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-7329
Practice Address - Country:US
Practice Address - Phone:405-837-1033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OK183717225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist