Provider Demographics
NPI:1831525021
Name:HOAGLAND, LACY (PTA)
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:HOAGLAND
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4264 E VISTA GRANDE
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-6483
Mailing Address - Country:US
Mailing Address - Phone:480-586-4107
Mailing Address - Fax:
Practice Address - Street 1:305 N PLAZA DR
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85120-5505
Practice Address - Country:US
Practice Address - Phone:480-982-7794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10510APTA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant