Provider Demographics
NPI:1326348897
Name:MCBRIDE, LAURIE L (PTA)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:L
Last Name:MCBRIDE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 PASTURE RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38351-3120
Mailing Address - Country:US
Mailing Address - Phone:731-967-2369
Mailing Address - Fax:731-660-2066
Practice Address - Street 1:180 W UNIVERSITY PKWY STE H
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-1612
Practice Address - Country:US
Practice Address - Phone:731-660-2065
Practice Address - Fax:731-660-2066
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPTA0000001872314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility