Provider Demographics
NPI:1447346036
Name:LACEY, KEVIN JAMES (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JAMES
Last Name:LACEY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23211 RED ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-9701
Mailing Address - Country:US
Mailing Address - Phone:269-668-5930
Mailing Address - Fax:269-668-5921
Practice Address - Street 1:23211 RED ARROW HWY
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-9701
Practice Address - Country:US
Practice Address - Phone:269-668-5930
Practice Address - Fax:269-668-5921
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2022-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070008138225100000X
MI5501010346225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650H000020OtherBCBS MI
MI155764OtherGREATLAKES HEALTH PLAN
MI650H000020OtherBCN MI
MI7993476OtherAETNA INS
MI310159700OtherACS/FED GOVT
MI6430129OtherIBA HEALTH PLANS
MI810584027OtherTAX ID
MI650H000020OtherBCBS MI
MI7993476OtherAETNA INS