Provider Demographics
NPI:1780972281
Name:GODBOLD, LACEY I (DPT)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:I
Last Name:GODBOLD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 BELLE CHASSE HWY
Mailing Address - Street 2:SUITE 208
Mailing Address - City:TERRYTOWN
Mailing Address - State:LA
Mailing Address - Zip Code:70056-7156
Mailing Address - Country:US
Mailing Address - Phone:504-433-8744
Mailing Address - Fax:504-433-8740
Practice Address - Street 1:2600 BELLE CHASSE HWY
Practice Address - Street 2:SUITE I
Practice Address - City:TERRYTOWN
Practice Address - State:LA
Practice Address - Zip Code:70056-7156
Practice Address - Country:US
Practice Address - Phone:504-391-7670
Practice Address - Fax:504-378-9437
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07633225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA07633OtherLOUISIANA PT LICENSE