Provider Demographics
NPI:1629189824
Name:LACKIE, BRUCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:LACKIE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:ORONO
Mailing Address - State:ME
Mailing Address - Zip Code:04473-3205
Mailing Address - Country:US
Mailing Address - Phone:207-866-0451
Mailing Address - Fax:
Practice Address - Street 1:56 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:ORONO
Practice Address - State:ME
Practice Address - Zip Code:04473-3205
Practice Address - Country:US
Practice Address - Phone:207-866-0451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC104131041C0700X
PACW 001208 L1041C0700X
NJSC-027161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PALA129259Medicare ID - Type UnspecifiedCSW