Provider Demographics
NPI:1619561313
Name:LACKEY, PHILLIP BRANDON (ATC)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:BRANDON
Last Name:LACKEY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 MS-25
Mailing Address - Street 2:
Mailing Address - City:AMORRY
Mailing Address - State:MS
Mailing Address - Zip Code:38821
Mailing Address - Country:US
Mailing Address - Phone:662-257-4048
Mailing Address - Fax:
Practice Address - Street 1:1112 MS-25
Practice Address - Street 2:
Practice Address - City:AMORRY
Practice Address - State:MS
Practice Address - Zip Code:38821
Practice Address - Country:US
Practice Address - Phone:662-257-4048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA4680225200000X
ALPTA6336225200000X
MSAT03582255A2300X
AL23732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer