Provider Demographics
NPI:1356895148
Name:MARTIN, LACY
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 YELLOWSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-9300
Mailing Address - Country:US
Mailing Address - Phone:307-587-9789
Mailing Address - Fax:307-587-9787
Practice Address - Street 1:544 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-9300
Practice Address - Country:US
Practice Address - Phone:307-587-9789
Practice Address - Fax:307-587-9787
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1885225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist