MEDICARE: LACIE WORTHAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	101628	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	46-5425549	OTHER	AK	MANUAL THERAPIST

General Provider Information

NPI Number	:	1306359641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACIE WORTHAM

Provider Business Mailing Address
First Line	:	4050 LAKE OTIS PKWY STE 101
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-5220
Country	:	US
Telephone Number	:	907-252-8958
Fax Number	:

Provider Business Practice Location Address
First Line	:	4050 LAKE OTIS PKWY STE 101
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-5220
Country	:	US
Telephone Number	:	907-252-8958
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2017
Last Update Date	:	05/06/2026

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Directions to “ LACIE WORTHAM ” Practice Location

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