Provider Demographics
NPI:1396831905
Name:LACKEY, BARBARA A (M; EP)
Entity Type:Individual
Prefix:DR
First Name:BARBARA
Middle Name:A
Last Name:LACKEY
Suffix:
Gender:F
Credentials:M; EP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33681 HALYARD DRIVE
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-4422
Mailing Address - Country:US
Mailing Address - Phone:949-240-9990
Mailing Address - Fax:949-240-9995
Practice Address - Street 1:242 WEST MAIN STREET SUITE 200E
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-0000
Practice Address - Country:US
Practice Address - Phone:714-838-4174
Practice Address - Fax:949-240-9995
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1352763OtherELECTRONIC HEALTH CARE