Provider Demographics
NPI:1174682504
Name:LACKEY, PHYLLIS J (LIC PROF COUNSELOR)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:J
Last Name:LACKEY
Suffix:
Gender:F
Credentials:LIC PROF COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 FORDWAY DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377
Mailing Address - Country:US
Mailing Address - Phone:937-890-3139
Mailing Address - Fax:937-890-3111
Practice Address - Street 1:482 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385
Practice Address - Country:US
Practice Address - Phone:937-374-6010
Practice Address - Fax:937-374-6014
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0003153101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor