Provider Demographics
NPI:1154801165
Name:LACY, SHAYNA COLLEEN
Entity type:Individual
Prefix:
First Name:SHAYNA
Middle Name:COLLEEN
Last Name:LACY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 W RANDOL MILL RD FL 6
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-2504
Mailing Address - Country:US
Mailing Address - Phone:682-276-8700
Mailing Address - Fax:
Practice Address - Street 1:721 DUNAWAY LN
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020
Practice Address - Country:US
Practice Address - Phone:817-444-2536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-19
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118481225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist