Provider Demographics
NPI:1366996639
Name:RAE, LACEY
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:RAE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:120 S BROAD ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:GROVE CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16127-1544
Mailing Address - Country:US
Mailing Address - Phone:724-458-1500
Mailing Address - Fax:724-458-1501
Practice Address - Street 1:120 S BROAD ST
Practice Address - Street 2:SUITE A
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127-1544
Practice Address - Country:US
Practice Address - Phone:724-458-1500
Practice Address - Fax:724-458-1501
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-04
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC014811174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist