Provider Demographics
NPI:1083991780
Name:SECREST, JOE DAVID IV (LMT)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:DAVID
Last Name:SECREST
Suffix:IV
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 EDWARDS RANCH RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4126
Mailing Address - Country:US
Mailing Address - Phone:843-345-3271
Mailing Address - Fax:
Practice Address - Street 1:5800 EDWARDS RANCH RD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4126
Practice Address - Country:US
Practice Address - Phone:843-345-3271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT120063225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist