Provider Demographics
NPI:1114165636
Name:LACK, LAURIE (LPCC)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:LACK
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVENUE
Mailing Address - Street 2:ML 5021
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3039
Mailing Address - Country:US
Mailing Address - Phone:513-636-4255
Mailing Address - Fax:513-636-2511
Practice Address - Street 1:3333 BURNET AVENUE
Practice Address - Street 2:ML 6015
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3039
Practice Address - Country:US
Practice Address - Phone:513-636-0800
Practice Address - Fax:513-636-0810
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0007901101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional