Provider Demographics
NPI:1114575529
Name:LACKE, KEVIN (DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:LACKE
Suffix:
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6611 ZEQUIEL DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78744-7231
Mailing Address - Country:US
Mailing Address - Phone:508-446-1756
Mailing Address - Fax:
Practice Address - Street 1:747 TEXAS 71 FRONTAGE RD
Practice Address - Street 2:SUITE B-200
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602
Practice Address - Country:US
Practice Address - Phone:512-920-6512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1322490225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist