Provider Demographics
NPI:1043335680
Name:LACKEY, LISA (MS, LCPC,CSAT,CMAT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LACKEY
Suffix:
Gender:F
Credentials:MS, LCPC,CSAT,CMAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 SHERMAN AVE STE 324
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-5013
Mailing Address - Country:US
Mailing Address - Phone:847-328-7588
Mailing Address - Fax:
Practice Address - Street 1:1609 SHERMAN AVE STE 324
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-5013
Practice Address - Country:US
Practice Address - Phone:847-328-7588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.004500101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional