Healthcare Provider Details

I. General information

NPI: 1821464611
Provider Name (Legal Business Name): LACEY CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2015
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 GREENE ST
WEBSTER TX
77598
US

IV. Provider business mailing address

2516 WINGED DOVE DR N/A
LEAGUE CITY TX
77573-3230
US

V. Phone/Fax

Practice location:
  • Phone: 281-332-4738
  • Fax:
Mailing address:
  • Phone: 817-938-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number113341
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: