Provider Demographics
NPI:1487621173
Name:LACEY, MICHAEL J (MPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:LACEY
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 GOLDEN EYE CT
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-9250
Mailing Address - Country:US
Mailing Address - Phone:803-767-9431
Mailing Address - Fax:
Practice Address - Street 1:3240 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3428
Practice Address - Country:US
Practice Address - Phone:803-796-8377
Practice Address - Fax:803-796-8378
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01093000225100000X
SC5400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist