Provider Demographics
NPI:1811322845
Name:MCROY, LACEY (PT)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:MCROY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 KEPLER DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8321
Mailing Address - Country:US
Mailing Address - Phone:920-288-8000
Mailing Address - Fax:
Practice Address - Street 1:1160 KEPLER DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-8321
Practice Address - Country:US
Practice Address - Phone:920-288-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070020112208100000X, 2081S0010X
WI13273225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070020112Medicaid