Provider Demographics
NPI:1457945057
Name:BOOTH, LACEY ANITA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:ANITA
Last Name:BOOTH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 SAULS ST STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-2677
Mailing Address - Country:US
Mailing Address - Phone:843-374-0185
Mailing Address - Fax:843-374-0189
Practice Address - Street 1:148 SAULS ST STE B
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2677
Practice Address - Country:US
Practice Address - Phone:843-374-0185
Practice Address - Fax:843-374-0189
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9459225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist