Provider Demographics
NPI:1508673187
Name:LACEY, TERESA
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:LACEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 PARK PLACE BLVD APT 707
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-5850
Mailing Address - Country:US
Mailing Address - Phone:817-343-6213
Mailing Address - Fax:
Practice Address - Street 1:2412 OLD NORTH RD STE 100B
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76209-1524
Practice Address - Country:US
Practice Address - Phone:817-343-6213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT132723225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist