Provider Demographics
NPI:1962539338
Name:WESTON, LACEY LEANN (LPTA)
Entity type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:LEANN
Last Name:WESTON
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 134
Mailing Address - Street 2:
Mailing Address - City:SAGE
Mailing Address - State:AR
Mailing Address - Zip Code:72573
Mailing Address - Country:US
Mailing Address - Phone:870-291-0361
Mailing Address - Fax:
Practice Address - Street 1:889 EAST MAIN ST.
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:AR
Practice Address - Zip Code:72556
Practice Address - Country:US
Practice Address - Phone:870-368-4586
Practice Address - Fax:870-368-4587
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2053225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR122852742Medicaid
AR145863778Medicaid
AR160417721Medicaid