Provider Demographics
NPI:1740744937
Name:DANIEL, LACIE (PTA)
Entity type:Individual
Prefix:
First Name:LACIE
Middle Name:
Last Name:DANIEL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8612 GUADALUPE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-6702
Mailing Address - Country:US
Mailing Address - Phone:682-556-9556
Mailing Address - Fax:
Practice Address - Street 1:721 DUNAWAY LN
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-2605
Practice Address - Country:US
Practice Address - Phone:817-444-2536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2136356225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant