Provider Demographics
NPI:1659654960
Name:LACKEY, BENJAMIN THOMAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:THOMAS
Last Name:LACKEY
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 1:18225 DETROIT AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-3321
Mailing Address - Country:US
Mailing Address - Phone:330-635-7450
Mailing Address - Fax:815-417-6462
Practice Address - Street 1:18225 DETROIT AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-3321
Practice Address - Country:US
Practice Address - Phone:330-635-7450
Practice Address - Fax:815-417-6462
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral