Healthcare Provider Details

I. General information

NPI: 1043148836
Provider Name (Legal Business Name): LACEY ROBERSON
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3803 RAINBOW DR
RAINBOW CITY AL
35906-3025
US

IV. Provider business mailing address

695 MOUNTAIN HOME LOOP
CEDARTOWN GA
30125-4237
US

V. Phone/Fax

Practice location:
  • Phone: 706-767-3085
  • Fax:
Mailing address:
  • Phone: 706-767-3085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number6997
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: