Provider Demographics
NPI:1245425735
Name:FASSETT, VAIL (MOTL,LMT, CMLOT-LANA)
Entity Type:Individual
Prefix:
First Name:VAIL
Middle Name:
Last Name:FASSETT
Suffix:
Gender:F
Credentials:MOTL,LMT, CMLOT-LANA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11880 GREENVILLE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3568
Mailing Address - Country:US
Mailing Address - Phone:214-349-6178
Mailing Address - Fax:
Practice Address - Street 1:11880 GREENVILLE AVE STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-3568
Practice Address - Country:US
Practice Address - Phone:214-349-6178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-08
Last Update Date:2007-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102723225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist