Provider Demographics
NPI:1255933479
Name:REZUCHA, LACEY JAYMES (DPT)
Entity type:Individual
Prefix:MISS
First Name:LACEY
Middle Name:JAYMES
Last Name:REZUCHA
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 1:153 OAKDALE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-1007
Mailing Address - Country:US
Mailing Address - Phone:607-217-0825
Mailing Address - Fax:607-217-0829
Practice Address - Street 1:153 OAKDALE RD STE 2
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-1007
Practice Address - Country:US
Practice Address - Phone:607-217-0825
Practice Address - Fax:607-217-0829
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045963-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist