Provider Demographics
NPI:1053504449
Name:LACKEY, NICOLE (MSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LACKEY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S. 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:ISHPEMING
Mailing Address - State:MI
Mailing Address - Zip Code:49849-2197
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 S. 4TH STREET
Practice Address - Street 2:
Practice Address - City:ISHPEMING
Practice Address - State:MI
Practice Address - Zip Code:49849-2197
Practice Address - Country:US
Practice Address - Phone:906-485-2153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI6801069258104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8008947750Medicare PIN