Basic Information
| Provider Information | |||||||||
| NPI: | 1659768422 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACOUR | ||||||||
| FirstName: | KELLY | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2603 | ||||||||
| Address2: | HTN, CLIENT ACCOUNTING | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761132603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175694300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2222 WELBORN ST | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752193924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145597790 | ||||||||
| FaxNumber: | 2142243818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2015 | ||||||||
| LastUpdateDate: | 07/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 109980 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 345158501 | 05 | TX | MEDICAID | 8FAH08 | 01 | TX | BCBS | OTHER |