Provider Demographics
NPI:1710485412
Name:TRLICEK, LEAH KARA (LMT)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:KARA
Last Name:TRLICEK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:TRLICEK
Other - Last Name:DODDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:3711 FRINGE BREEZE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78261-2808
Mailing Address - Country:US
Mailing Address - Phone:361-571-5272
Mailing Address - Fax:
Practice Address - Street 1:14802 JONES MALTSBERGER RD STE 1101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-3761
Practice Address - Country:US
Practice Address - Phone:210-315-3684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-28
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT112567225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT112567OtherMASSAGE THERAPY