Basic Information
| Provider Information | |||||||||
| NPI: | 1811322845 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCROY | ||||||||
| FirstName: | LACEY | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 KEPLER DR | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543118321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202888000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1160 KEPLER DR | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543118321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202888000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2013 | ||||||||
| LastUpdateDate: | 01/12/2016 | ||||||||
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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 | 208100000X | 070020112 | IL | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081S0010X | 070020112 | IL | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine | 225100000X | 13273 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 070020112 | 05 | IL | MEDICAID |