Provider Demographics
NPI:1073123543
Name:REID, CONNIE LAVONNE (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:LAVONNE
Last Name:REID
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 ABEL DR
Mailing Address - Street 2:
Mailing Address - City:GLENN HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:75154-3862
Mailing Address - Country:US
Mailing Address - Phone:469-323-0560
Mailing Address - Fax:
Practice Address - Street 1:216 ABEL DR
Practice Address - Street 2:
Practice Address - City:GLENN HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:75154-3862
Practice Address - Country:US
Practice Address - Phone:469-323-0560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-08
Last Update Date:2020-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX224P00000X, 1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist