Provider Demographics
NPI:1144719592
Name:LACKNER, KENDALL JO (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:JO
Last Name:LACKNER
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 CALVARY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLEROI
Mailing Address - State:PA
Mailing Address - Zip Code:15022-1128
Mailing Address - Country:US
Mailing Address - Phone:724-678-4814
Mailing Address - Fax:
Practice Address - Street 1:1755 WITTINGTON PL STE 175
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-1905
Practice Address - Country:US
Practice Address - Phone:214-442-4210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA00119-007728225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist