Provider Demographics
NPI:1124678032
Name:MORALES, LAURA MICHELLE (PTA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MICHELLE
Last Name:MORALES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 GANDY ST
Mailing Address - Street 2:
Mailing Address - City:LIPAN
Mailing Address - State:TX
Mailing Address - Zip Code:76462-2412
Mailing Address - Country:US
Mailing Address - Phone:817-776-7366
Mailing Address - Fax:
Practice Address - Street 1:202 S HARTFORD ST
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:TX
Practice Address - Zip Code:76424-4713
Practice Address - Country:US
Practice Address - Phone:254-559-1864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2147670225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant