Healthcare Provider Details

I. General information

NPI: 1972985893
Provider Name (Legal Business Name): MAURA LEIGH LACEY DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2015
Last Update Date: 06/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 BRANDYWINE DR
MC MURRAY PA
15317-3600
US

IV. Provider business mailing address

112 BRANDYWINE DR
MC MURRAY PA
15317-3600
US

V. Phone/Fax

Practice location:
  • Phone: 724-263-3792
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 003470
License Number StateWV

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: