Provider Demographics
NPI:1174068373
Name:WINDSOR, LACIE
Entity type:Individual
Prefix:
First Name:LACIE
Middle Name:
Last Name:WINDSOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1537 EDGEWATER LN
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-3667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1492 TINY TOWN RD STE A1A2
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-7873
Practice Address - Country:US
Practice Address - Phone:615-758-1030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-23
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16126225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNJZKXZ9581251OtherBLUECROSS BLUESHIELD