Provider Demographics
NPI:1740541226
Name:LACKI, EILEEN JANIS (PTA)
Entity type:Individual
Prefix:MRS
First Name:EILEEN
Middle Name:JANIS
Last Name:LACKI
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:EILEEN
Other - Middle Name:JANIS
Other - Last Name:O'BRIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:6447 FAIRWAY VIEW BLVD S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-3815
Mailing Address - Country:US
Mailing Address - Phone:727-209-0579
Mailing Address - Fax:
Practice Address - Street 1:5535 PARK ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-6309
Practice Address - Country:US
Practice Address - Phone:727-209-0579
Practice Address - Fax:727-209-0580
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA18384225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant