Provider Demographics
NPI:1437441854
Name:LAKE CITIES ELITE PERFORMANCE THERAPY
Entity Type:Organization
Organization Name:LAKE CITIES ELITE PERFORMANCE THERAPY
Other - Org Name:ELITE PERFORMANCE THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/THERAPIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:ANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDO
Authorized Official - Suffix:
Authorized Official - Credentials:OTR, MOT
Authorized Official - Phone:855-204-4540
Mailing Address - Street 1:109 RED BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:HICKORY CREEK
Mailing Address - State:TX
Mailing Address - Zip Code:75065-3618
Mailing Address - Country:US
Mailing Address - Phone:855-204-4540
Mailing Address - Fax:940-293-8555
Practice Address - Street 1:109 RED BLUFF DR
Practice Address - Street 2:
Practice Address - City:HICKORY CREEK
Practice Address - State:TX
Practice Address - Zip Code:75065-3618
Practice Address - Country:US
Practice Address - Phone:855-204-4540
Practice Address - Fax:940-293-8555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX563080000225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty