Provider Demographics
NPI:1245896836
Name:LACK, ASHLEY (MPT)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:LACK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 STATE ST
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-3461
Mailing Address - Country:US
Mailing Address - Phone:618-540-2979
Mailing Address - Fax:
Practice Address - Street 1:20 JUNCTION DR W STE 4
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-3060
Practice Address - Country:US
Practice Address - Phone:618-288-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-19
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009034462225100000X
IL070.019121225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist