Provider Demographics
NPI:1194976340
Name:MASON, LACEY D (PT)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:D
Last Name:MASON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:D
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:SKOWHEGAN
Mailing Address - State:ME
Mailing Address - Zip Code:04976-0468
Mailing Address - Country:US
Mailing Address - Phone:207-858-8367
Mailing Address - Fax:207-474-9261
Practice Address - Street 1:57 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:SKOWHEGAN
Practice Address - State:ME
Practice Address - Zip Code:04976-1414
Practice Address - Country:US
Practice Address - Phone:207-474-7000
Practice Address - Fax:207-858-4772
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT3454225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME3454OtherME STATE LICENSE