Provider Demographics
NPI:1013269760
Name:LACKETT, KELLI ELLEN (MS)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ELLEN
Last Name:LACKETT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1148 E ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4068
Mailing Address - Country:US
Mailing Address - Phone:970-472-4133
Mailing Address - Fax:970-493-6655
Practice Address - Street 1:1148 E ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4068
Practice Address - Country:US
Practice Address - Phone:970-472-4133
Practice Address - Fax:970-493-6655
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-04
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist