Basic Information
| Provider Information | |||||||||
| NPI: | 1568945970 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACEY | ||||||||
| FirstName: | MICAELA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6396 WOODBROOK CT | ||||||||
| Address2: | |||||||||
| City: | LINDEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484519671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8108145420 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3601 W 13 MILE RD | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480736712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488985000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2018 | ||||||||
| LastUpdateDate: | 09/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5201010079 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.