Provider Demographics
NPI:1013221928
Name:DEMOTT, LOU ELLEN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:LOU
Middle Name:ELLEN
Last Name:DEMOTT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 PHEASANT RUN
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-6120
Mailing Address - Country:US
Mailing Address - Phone:817-271-2033
Mailing Address - Fax:
Practice Address - Street 1:136 W BUFFORD ST
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-4227
Practice Address - Country:US
Practice Address - Phone:817-426-2456
Practice Address - Fax:817-426-0149
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT106959225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist