Provider Demographics
NPI:1598247983
Name:PENWELL, LACY (PTA)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:PENWELL
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 1:303 COUNTY ROAD 44750
Mailing Address - Street 2:
Mailing Address - City:BLOSSOM
Mailing Address - State:TX
Mailing Address - Zip Code:75416-3916
Mailing Address - Country:US
Mailing Address - Phone:903-905-0499
Mailing Address - Fax:
Practice Address - Street 1:1675 NE LOOP 286
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-2219
Practice Address - Country:US
Practice Address - Phone:903-782-9922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2136091225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant