Provider Demographics
NPI:1508099144
Name:LACKEY, AMY RAYE (SLP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:RAYE
Last Name:LACKEY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:RAYE
Other - Last Name:LESSING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:819 WATER ST
Mailing Address - Street 2:STE 300
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-5333
Mailing Address - Country:US
Mailing Address - Phone:830-792-3300
Mailing Address - Fax:830-792-5771
Practice Address - Street 1:819 WATER ST
Practice Address - Street 2:STE 300
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5333
Practice Address - Country:US
Practice Address - Phone:830-792-3300
Practice Address - Fax:830-792-5771
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103370235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103370OtherLICENSE