Provider Demographics
NPI:1689437832
Name:LACKS, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:LACKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 WAMPUS AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-4813
Mailing Address - Country:US
Mailing Address - Phone:919-723-8051
Mailing Address - Fax:
Practice Address - Street 1:5 WAMPUS AVE APT 7
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-4813
Practice Address - Country:US
Practice Address - Phone:919-723-8051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA518826103TS0200X
MALEP1260103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool