Provider Demographics
NPI:1558841288
Name:FORD, LYNETTE BLANCHE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:LYNETTE
Middle Name:BLANCHE
Last Name:FORD
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 1:3540 CRESTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-4605
Mailing Address - Country:US
Mailing Address - Phone:817-408-3800
Mailing Address - Fax:817-408-3900
Practice Address - Street 1:3540 CRESTRIDGE DR
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-4605
Practice Address - Country:US
Practice Address - Phone:817-408-3800
Practice Address - Fax:817-408-3900
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2024032225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant