MEDICARE: PHYSICAL THERAPIST

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	225100000X	Physical Therapist	39149	CA

General Provider Information

NPI Number	:	1326440934
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICAL THERAPIST

Provider Business Mailing Address
First Line	:	2614 JASMINE ST
Second Line	:
City	:	NATIONAL CITY
State	:	CA
Zip	:	91950-6253
Country	:	US
Telephone Number	:	480-577-1398
Fax Number	:

Provider Business Practice Location Address
First Line	:	2614 JASMINE ST
Second Line	:
City	:	NATIONAL CITY
State	:	CA
Zip	:	91950-6253
Country	:	US
Telephone Number	:	480-577-1398
Fax Number	:

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	DR. MICHELLE E LACEY
Credential	:	DPT
Telephone Number	:	480-577-1398

Provider Enumeration Date	:	09/25/2014
Last Update Date	:	09/25/2014

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Directions to “PHYSICAL THERAPIST ” Practice Location

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