Provider Demographics
NPI:1679053672
Name:LANTRIP-PRUETT, KASEY JO (PTA)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:JO
Last Name:LANTRIP-PRUETT
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 1:608 CADDELL ST
Mailing Address - Street 2:
Mailing Address - City:AUBREY
Mailing Address - State:TX
Mailing Address - Zip Code:76227-9231
Mailing Address - Country:US
Mailing Address - Phone:940-390-0084
Mailing Address - Fax:
Practice Address - Street 1:205 N BONNIE BRAE ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-3766
Practice Address - Country:US
Practice Address - Phone:940-703-7227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-19
Last Update Date:2018-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2083287225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant