Provider Demographics
NPI:1659770667
Name:LACKEY, COURTNEY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:LACKEY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7030 SW 174TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-6403
Mailing Address - Country:US
Mailing Address - Phone:503-507-0461
Mailing Address - Fax:
Practice Address - Street 1:17762 NW COUNTRY DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-8541
Practice Address - Country:US
Practice Address - Phone:503-946-5375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR013431235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist