Provider Demographics
NPI:1053776864
Name:JUELFS, LACEY (PTA)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:JUELFS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 6TH AVE SW
Mailing Address - Street 2:PO BOX C
Mailing Address - City:BOWMAN
Mailing Address - State:ND
Mailing Address - Zip Code:58623-4518
Mailing Address - Country:US
Mailing Address - Phone:701-523-3226
Mailing Address - Fax:
Practice Address - Street 1:12 6TH AVE SW
Practice Address - Street 2:PO BOX C
Practice Address - City:BOWMAN
Practice Address - State:ND
Practice Address - Zip Code:58623-4518
Practice Address - Country:US
Practice Address - Phone:701-523-3226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1056225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant