Provider Demographics
NPI:1194785444
Name:ROBERTS, LACEY LYNNE (BS PT)
Entity type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:LYNNE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:BS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 HERBERT DR
Mailing Address - Street 2:
Mailing Address - City:HENSLEY
Mailing Address - State:AR
Mailing Address - Zip Code:72065-9512
Mailing Address - Country:US
Mailing Address - Phone:501-888-3229
Mailing Address - Fax:501-888-3229
Practice Address - Street 1:231 HERBERT DR
Practice Address - Street 2:
Practice Address - City:HENSLEY
Practice Address - State:AR
Practice Address - Zip Code:72065-9512
Practice Address - Country:US
Practice Address - Phone:501-888-3229
Practice Address - Fax:501-888-3229
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT936225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR16607721Medicaid
AR5S380OtherBCBS