Provider Demographics
NPI:1679145668
Name:LACEFIELD, KRYSTYNA MICHELLE (COTA)
Entity type:Individual
Prefix:MISS
First Name:KRYSTYNA
Middle Name:MICHELLE
Last Name:LACEFIELD
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 N ROSS AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:MEXIA
Mailing Address - State:TX
Mailing Address - Zip Code:76667-2201
Mailing Address - Country:US
Mailing Address - Phone:903-388-2494
Mailing Address - Fax:
Practice Address - Street 1:15820 ADDISON RD
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-3549
Practice Address - Country:US
Practice Address - Phone:866-919-3240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-11
Last Update Date:2021-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216899224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty