Provider Demographics
NPI:1295006369
Name:HEDRICK, LACY DANIELLE
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:DANIELLE
Last Name:HEDRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2575 AIRLINE DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-5812
Mailing Address - Country:US
Mailing Address - Phone:318-272-2488
Mailing Address - Fax:
Practice Address - Street 1:2575 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-5812
Practice Address - Country:US
Practice Address - Phone:318-459-7520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-21
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA7946225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant