Provider Demographics
NPI:1437206422
Name:LACKEY, WILBURN H (EDD LPC LSOT)
Entity Type:Individual
Prefix:DR
First Name:WILBURN
Middle Name:H
Last Name:LACKEY
Suffix:
Gender:M
Credentials:EDD LPC LSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 997
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:79073-0997
Mailing Address - Country:US
Mailing Address - Phone:806-774-3935
Mailing Address - Fax:806-293-1267
Practice Address - Street 1:3109 OLTON RD
Practice Address - Street 2:105E
Practice Address - City:PLAINVIEW
Practice Address - State:TX
Practice Address - Zip Code:79072-6763
Practice Address - Country:US
Practice Address - Phone:806-293-8402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12383101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX12383OtherL.P.C. LICENSE
TX95294OtherLSOTP LICENSE