Provider Demographics
NPI:1679921506
Name:PETMECKY, LEWIS THOMAS (LAT)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:THOMAS
Last Name:PETMECKY
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14001 HIGHWAY 46 W
Mailing Address - Street 2:
Mailing Address - City:SPRING BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:78070-7053
Mailing Address - Country:US
Mailing Address - Phone:210-559-0182
Mailing Address - Fax:
Practice Address - Street 1:14001 HIGHWAY 46 W
Practice Address - Street 2:
Practice Address - City:SPRING BRANCH
Practice Address - State:TX
Practice Address - Zip Code:78070-7053
Practice Address - Country:US
Practice Address - Phone:210-559-0182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT08082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer