Individual
KELLY LACOUR
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OT
Contact information
Practice address
2222 WELBORN ST, DALLAS, TX 75219-3924
(214) 559-7790
(214) 224-3818
Mailing address
PO BOX 2603, HTN, CLIENT ACCOUNTING, FORT WORTH, TX 76113-2603
(817) 569-4300
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
109980
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
345158501
—
TX
01
—
8FAH08
BCBS
TX
Enumeration date
04/20/2015
Last updated
07/15/2019
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