Provider Demographics
NPI:1912048968
Name:PRADERVAND, MEREDYTH LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:MEREDYTH
Middle Name:LYNN
Last Name:PRADERVAND
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 1:228 NE WILSHIRE BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-4126
Mailing Address - Country:US
Mailing Address - Phone:817-295-4400
Mailing Address - Fax:
Practice Address - Street 1:228 NE WILSHIRE BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-4126
Practice Address - Country:US
Practice Address - Phone:817-295-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT042023174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist