Provider Demographics
NPI:1922343615
Name:SWAILS, LAURIE JEAN (LMT, MMP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:JEAN
Last Name:SWAILS
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 MANSFIELD DRIVE UNIT 107
Mailing Address - Street 2:
Mailing Address - City:PORT MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:78598
Mailing Address - Country:US
Mailing Address - Phone:956-642-6004
Mailing Address - Fax:956-944-2184
Practice Address - Street 1:211 NORTH SHORE DRIVE
Practice Address - Street 2:
Practice Address - City:PORT MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:78598
Practice Address - Country:US
Practice Address - Phone:956-642-6004
Practice Address - Fax:956-944-2184
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT116057225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist