Provider Demographics
NPI:1649534751
Name:ROSS, LACEY ELIZABETH (DPT)
Entity type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:ELIZABETH
Last Name:ROSS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:LACEY
Other - Middle Name:ELIZABETH
Other - Last Name:BELCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:914 S SCHEUBER RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9027
Mailing Address - Country:US
Mailing Address - Phone:360-330-8844
Mailing Address - Fax:360-330-8623
Practice Address - Street 1:1900 COOKS HILL RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9073
Practice Address - Country:US
Practice Address - Phone:360-330-8627
Practice Address - Fax:360-330-8786
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60217733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1801989587Medicare UPIN