Provider Demographics
NPI:1891254199
Name:LACKEY, MONICA SHAWNTAE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:SHAWNTAE
Last Name:LACKEY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1064 KINGS MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-4929
Mailing Address - Country:US
Mailing Address - Phone:704-622-0296
Mailing Address - Fax:
Practice Address - Street 1:150 KEN DWIGGINS DR
Practice Address - Street 2:
Practice Address - City:MOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27028-2439
Practice Address - Country:US
Practice Address - Phone:336-751-1209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-16
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
NC10933225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist