Provider Demographics
NPI:1043595994
Name:FORDYCE, LAURA ELLAN (COTA/L)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ELLAN
Last Name:FORDYCE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2351 W NORTHWEST HWY
Mailing Address - Street 2:SUITE 3270
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75220-4433
Mailing Address - Country:US
Mailing Address - Phone:972-661-0883
Mailing Address - Fax:
Practice Address - Street 1:2351 W NORTHWEST HWY
Practice Address - Street 2:SUITE 3270
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75220-4433
Practice Address - Country:US
Practice Address - Phone:972-661-0883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1073224Z00000X
TX210773224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant