Provider Demographics
NPI:1669018917
Name:MILES, LACY ROSE (COTA)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:ROSE
Last Name:MILES
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 PRICE ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75670-3523
Mailing Address - Country:US
Mailing Address - Phone:903-742-1997
Mailing Address - Fax:
Practice Address - Street 1:415 S 1ST ST STE 300A
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-3863
Practice Address - Country:US
Practice Address - Phone:936-225-1174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216015224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant