MEDICARE: LACEY VOSS OT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	123801	TX

General Provider Information

NPI Number	:	1639850985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACEY VOSS OT

Provider Business Mailing Address
First Line	:	9020 SUMMIT PENINSULA RD APT 2207
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2350
Country	:	US
Telephone Number	:	817-915-2725
Fax Number	:

Provider Business Practice Location Address
First Line	:	9020 SUMMIT PENINSULA RD APT 2207
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2350
Country	:	US
Telephone Number	:	817-915-2725
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2023
Last Update Date	:	07/28/2023

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Directions to “ LACEY VOSS OT” Practice Location

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