Provider Demographics
NPI:1144533993
Name:REYNOLDS, LACEY BASCOM (OT)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:BASCOM
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 E 300 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-3539
Mailing Address - Country:US
Mailing Address - Phone:801-852-4525
Mailing Address - Fax:
Practice Address - Street 1:1165 E 300 N
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-3539
Practice Address - Country:US
Practice Address - Phone:801-852-4525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8428814-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist