Provider Demographics
NPI:1275371809
Name:LACY, KIANNA JANAE (OT)
Entity type:Individual
Prefix:
First Name:KIANNA
Middle Name:JANAE
Last Name:LACY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 N LOOP 288 APT 3302
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76208-7707
Mailing Address - Country:US
Mailing Address - Phone:817-727-3071
Mailing Address - Fax:
Practice Address - Street 1:17516 MATANY RD STE 100
Practice Address - Street 2:
Practice Address - City:JUSTIN
Practice Address - State:TX
Practice Address - Zip Code:76247-8707
Practice Address - Country:US
Practice Address - Phone:940-654-4011
Practice Address - Fax:844-440-2104
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX124732225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist