Provider Demographics
NPI:1336024447
Name:DAVIDSON, LACEY ANNE
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:ANNE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9307 57TH AVE SW APT U104
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-6133
Mailing Address - Country:US
Mailing Address - Phone:253-754-7216
Mailing Address - Fax:
Practice Address - Street 1:9307 57TH AVE SW APT U104
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-6133
Practice Address - Country:US
Practice Address - Phone:253-754-7216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-07
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60806117225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist