Provider Demographics
NPI:1588855662
Name:PATRICIA J LACKEY PHD PA
Entity Type:Organization
Organization Name:PATRICIA J LACKEY PHD PA
Other - Org Name:CANTON PSYCHOLOGICAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOLOGIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:LACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:410-499-7792
Mailing Address - Street 1:13801 YORK RD
Mailing Address - Street 2:K14
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030-1895
Mailing Address - Country:US
Mailing Address - Phone:410-499-7792
Mailing Address - Fax:410-732-7427
Practice Address - Street 1:2801 FOSTER AVENUE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-3816
Practice Address - Country:US
Practice Address - Phone:410-499-7792
Practice Address - Fax:410-732-7427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03096103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDK74OtherMD BC AND BS
MD684LMedicare PIN