Provider Demographics
NPI:1043960859
Name:LACKEY, KANZIS MALON
Entity Type:Individual
Prefix:
First Name:KANZIS
Middle Name:MALON
Last Name:LACKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 SADDLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-5522
Mailing Address - Country:US
Mailing Address - Phone:704-450-1006
Mailing Address - Fax:
Practice Address - Street 1:31 E MAIN AVE
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28681-2540
Practice Address - Country:US
Practice Address - Phone:704-872-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)