Provider Demographics
NPI:1275012916
Name:EDWARDS, LACRETIA COOKE (MPT)
Entity Type:Individual
Prefix:
First Name:LACRETIA
Middle Name:COOKE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:DEMOPOLIS
Mailing Address - State:AL
Mailing Address - Zip Code:36732-0446
Mailing Address - Country:US
Mailing Address - Phone:334-247-2042
Mailing Address - Fax:
Practice Address - Street 1:25185 HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AL
Practice Address - Zip Code:36756-6038
Practice Address - Country:US
Practice Address - Phone:334-247-2042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PTH3253225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist