Provider Demographics
NPI:1942439294
Name:LACKENBY, DAVID (PT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:LACKENBY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5920 TROPICAL DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-1729
Mailing Address - Country:US
Mailing Address - Phone:239-565-4443
Mailing Address - Fax:
Practice Address - Street 1:7331 COLLEGE PKWY STE 300
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5524
Practice Address - Country:US
Practice Address - Phone:239-337-2003
Practice Address - Fax:239-337-3168
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-08
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7411225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL882708700Medicaid