Healthcare Provider Details

I. General information

NPI: 1609584424
Provider Name (Legal Business Name): MRS. LAKERRICA JANELL HANCOCK-ALLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2022
Last Update Date: 11/10/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 GREENBRIAR DR
SOUTHLAKE TX
76092-8355
US

IV. Provider business mailing address

5525 READING RD APT 103
ROSENBERG TX
77471-5784
US

V. Phone/Fax

Practice location:
  • Phone: 817-442-9022
  • Fax:
Mailing address:
  • Phone: 409-347-4918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number106S00000X
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: