Healthcare Provider Details

I. General information

NPI: 1013792795
Provider Name (Legal Business Name): LACEY MARIE WOODARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LACEY MARIE WOODARD-EMRO

II. Dates (important events)

Enumeration Date: 08/30/2023
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 SE 4TH ST
MOORE OK
73160-7329
US

IV. Provider business mailing address

1213 FOGGY BOTTOM RD
TECUMSEH OK
74873-1630
US

V. Phone/Fax

Practice location:
  • Phone: 405-837-1033
  • Fax:
Mailing address:
  • Phone: 940-704-5169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number183717
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: