Provider Demographics
NPI:1750772851
Name:RIFE, LACIE (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:LACIE
Middle Name:
Last Name:RIFE
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:LACIE
Other - Middle Name:
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:208 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:MONDAMIN
Mailing Address - State:IA
Mailing Address - Zip Code:51557-2031
Mailing Address - Country:US
Mailing Address - Phone:712-310-2015
Mailing Address - Fax:
Practice Address - Street 1:8200 DODGE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4113
Practice Address - Country:US
Practice Address - Phone:402-955-6351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-10
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1864225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025453300Medicaid