Basic Information
| Provider Information | |||||||||
| NPI: | 1316117831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACKEY | ||||||||
| FirstName: | MOLLIE | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LISW-S | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DELAWDER | ||||||||
| OtherFirstName: | MOLLIE | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 115 PRIVATE ROAD 977 | ||||||||
| Address2: | |||||||||
| City: | PEDRO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456598608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405341386 | ||||||||
| FaxNumber: | 7405341497 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 PRIVATE ROAD 977 | ||||||||
| Address2: | |||||||||
| City: | PEDRO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456598608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405341386 | ||||||||
| FaxNumber: | 7405341497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | S-0028697 | OH | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 1100136-SUPV | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.