Provider Demographics
NPI:1538575162
Name:LAKEISHA BRAZIEL - DAVIS LLC
Entity type:Organization
Organization Name:LAKEISHA BRAZIEL - DAVIS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAKEISHA
Authorized Official - Middle Name:N
Authorized Official - Last Name:BRAZIEL-DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-986-8732
Mailing Address - Street 1:321 CHRISTIE AVE
Mailing Address - Street 2:
Mailing Address - City:EVERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:76140-4520
Mailing Address - Country:US
Mailing Address - Phone:817-986-8732
Mailing Address - Fax:
Practice Address - Street 1:2601 PECOS ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76119-5609
Practice Address - Country:US
Practice Address - Phone:817-535-2688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services