Provider Demographics
NPI:1356812192
Name:KLEM, LACEY ELIZABETH ROSE (LMT)
Entity type:Individual
Prefix:MS
First Name:LACEY
Middle Name:ELIZABETH ROSE
Last Name:KLEM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85458 HYWY 11
Mailing Address - Street 2:
Mailing Address - City:MILTON FREEWATER
Mailing Address - State:OR
Mailing Address - Zip Code:97862
Mailing Address - Country:US
Mailing Address - Phone:541-938-8300
Mailing Address - Fax:541-938-3924
Practice Address - Street 1:85458 HYWY 11
Practice Address - Street 2:
Practice Address - City:MILTON FREEWATER
Practice Address - State:OR
Practice Address - Zip Code:97862
Practice Address - Country:US
Practice Address - Phone:541-938-8300
Practice Address - Fax:541-938-3924
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24742225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist