Provider Demographics
NPI:1568945574
Name:WETTIG, LAURA (OTR/L)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WETTIG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 CREEKWAY BND
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-9421
Mailing Address - Country:US
Mailing Address - Phone:817-584-2925
Mailing Address - Fax:
Practice Address - Street 1:4113 GATEWAY DR STE 200
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5942
Practice Address - Country:US
Practice Address - Phone:817-793-7764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119402225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist