Provider Demographics
NPI:1497235774
Name:BROWN, LEZLI (PTA)
Entity Type:Individual
Prefix:
First Name:LEZLI
Middle Name:
Last Name:BROWN
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 1:2264 JUSTUS ST APT 2306
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-2050
Mailing Address - Country:US
Mailing Address - Phone:214-287-2060
Mailing Address - Fax:
Practice Address - Street 1:4600 HERITAGE TRACE PKWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-8900
Practice Address - Country:US
Practice Address - Phone:817-741-9063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2040186225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant