Provider Demographics
NPI:1669981767
Name:LARTHRIDGE-MACK, KEVA (LMT)
Entity type:Individual
Prefix:
First Name:KEVA
Middle Name:
Last Name:LARTHRIDGE-MACK
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 1:2306 OAK LN STE 15
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-8819
Mailing Address - Country:US
Mailing Address - Phone:817-851-8365
Mailing Address - Fax:817-696-9171
Practice Address - Street 1:2306 OAK LN STE 15
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-8819
Practice Address - Country:US
Practice Address - Phone:817-668-5382
Practice Address - Fax:817-696-9171
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT127989225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty