Provider Demographics
NPI:1689449803
Name:LACKMANN, MARK IRWIN (LADAC I; CADC I)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:IRWIN
Last Name:LACKMANN
Suffix:
Gender:M
Credentials:LADAC I; CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3045 LEERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38134-3613
Mailing Address - Country:US
Mailing Address - Phone:505-402-3138
Mailing Address - Fax:
Practice Address - Street 1:661 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3307
Practice Address - Country:US
Practice Address - Phone:901-267-4008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN-006101YA0400X
TNLDC0000001357101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)