Provider Demographics
NPI:1902215494
Name:LACKEY, KAREN
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:
Last Name:LACKEY
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 1:288 CRACKEL RD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:OH
Mailing Address - Zip Code:44202-6770
Mailing Address - Country:US
Mailing Address - Phone:440-552-1163
Mailing Address - Fax:
Practice Address - Street 1:12557 RAVENWOOD DR
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-9009
Practice Address - Country:US
Practice Address - Phone:440-285-2170
Practice Address - Fax:440-285-4552
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-08
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00090351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical