Provider Demographics
NPI:1841636610
Name:TYGENHOF, LACEY L (OTR/L)
Entity type:Individual
Prefix:MS
First Name:LACEY
Middle Name:L
Last Name:TYGENHOF
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 N HARBOR BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-4145
Mailing Address - Country:US
Mailing Address - Phone:714-870-5970
Mailing Address - Fax:
Practice Address - Street 1:1400 N HARBOR BLVD STE 300
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-4145
Practice Address - Country:US
Practice Address - Phone:714-870-5970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13830225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty