Provider Demographics
NPI:1821597964
Name:PROCELL, ILA (LMT)
Entity Type:Individual
Prefix:
First Name:ILA
Middle Name:
Last Name:PROCELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:MOODY
Mailing Address - State:TX
Mailing Address - Zip Code:76557-0367
Mailing Address - Country:US
Mailing Address - Phone:832-689-3513
Mailing Address - Fax:
Practice Address - Street 1:407 8TH ST
Practice Address - Street 2:
Practice Address - City:MOODY
Practice Address - State:TX
Practice Address - Zip Code:76557-3849
Practice Address - Country:US
Practice Address - Phone:832-689-3513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT031858225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMT031858OtherMASSAGE THERAPIST