Provider Demographics
NPI:1538442769
Name:FAIRBROTHER, LACEY R (PT, DPT)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:R
Last Name:FAIRBROTHER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:R
Other - Last Name:KNOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14890 SE 29TH ST
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-3515
Mailing Address - Country:US
Mailing Address - Phone:405-390-1731
Mailing Address - Fax:405-390-1981
Practice Address - Street 1:14890 SE 29TH ST
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-3515
Practice Address - Country:US
Practice Address - Phone:405-390-1731
Practice Address - Fax:405-390-1981
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4499225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist