Provider Demographics
NPI:1104124676
Name:HOLDER, LACEY (OTR/L)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:HOLDER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:FEDUKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2201 N CENTRAL EXPY STE 110
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-2718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2201 N CENTRAL EXPY STE 110
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-2718
Practice Address - Country:US
Practice Address - Phone:214-265-1819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-08
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113964225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics