Provider Demographics
NPI:1497262398
Name:DANIEL, ANGIE RAE LACKEY (LPC)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:RAE LACKEY
Last Name:DANIEL
Suffix:
Gender:F
Credentials:LPC
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 955
Mailing Address - Street 2:
Mailing Address - City:MUNFORD
Mailing Address - State:AL
Mailing Address - Zip Code:36268-0955
Mailing Address - Country:US
Mailing Address - Phone:256-649-0910
Mailing Address - Fax:
Practice Address - Street 1:65 MITCHELL STREET
Practice Address - Street 2:
Practice Address - City:MUNFORD
Practice Address - State:AL
Practice Address - Zip Code:36268
Practice Address - Country:US
Practice Address - Phone:256-649-0910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3814101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty