Provider Demographics
NPI:1619142973
Name:LACKEY, KIMBERLY J (MED)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:LACKEY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 RIVERBOTTOM RD
Mailing Address - Street 2:
Mailing Address - City:RONDA
Mailing Address - State:NC
Mailing Address - Zip Code:28670-9300
Mailing Address - Country:US
Mailing Address - Phone:828-850-5107
Mailing Address - Fax:
Practice Address - Street 1:360 RIVERBOTTOM RD
Practice Address - Street 2:
Practice Address - City:RONDA
Practice Address - State:NC
Practice Address - Zip Code:28670-9300
Practice Address - Country:US
Practice Address - Phone:828-850-5107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4877OtherNCLPC