Provider Demographics
NPI:1669233672
Name:PALACIOS, VANESSA GRACE (PTA)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:GRACE
Last Name:PALACIOS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:GRACE
Other - Last Name:HERRERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:3501 N MACARTHUR BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-3675
Mailing Address - Country:US
Mailing Address - Phone:972-256-3700
Mailing Address - Fax:866-630-6348
Practice Address - Street 1:2101 WESTPARK CT STE 100
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-3719
Practice Address - Country:US
Practice Address - Phone:972-256-3700
Practice Address - Fax:866-630-6348
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2151695225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant