Provider Demographics
NPI:1023377785
Name:LACKAMP, PATRICK (LAC)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:LACKAMP
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 E CENTENNIAL DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-6601
Mailing Address - Country:US
Mailing Address - Phone:620-231-5130
Mailing Address - Fax:
Practice Address - Street 1:810 CEDAR ST
Practice Address - Street 2:
Practice Address - City:GIRARD
Practice Address - State:KS
Practice Address - Zip Code:66743-2056
Practice Address - Country:US
Practice Address - Phone:620-724-8806
Practice Address - Fax:620-724-6170
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS466101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)