Provider Demographics
NPI:1639218977
Name:LACKEY, DALE H (PT)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:H
Last Name:LACKEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 MCCARTHY BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-2035
Mailing Address - Country:US
Mailing Address - Phone:252-658-3156
Mailing Address - Fax:617-762-2965
Practice Address - Street 1:1309 MCCARTHY BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-2035
Practice Address - Country:US
Practice Address - Phone:252-658-3156
Practice Address - Fax:617-762-2965
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6708225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC018TEOtherBLUE CROSS GROUP BILLING NUMBER