Provider Demographics
NPI:1326200437
Name:MOORE LACKEY, MARY KELLY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KELLY
Last Name:MOORE LACKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:THOMAS
Mailing Address - State:OK
Mailing Address - Zip Code:73669-0099
Mailing Address - Country:US
Mailing Address - Phone:806-613-4885
Mailing Address - Fax:
Practice Address - Street 1:3080 W 3RD ST
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-4323
Practice Address - Country:US
Practice Address - Phone:405-424-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional