Provider Demographics
NPI:1255603486
Name:LACKEY, CRYSTAL N (PT, DPT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:N
Last Name:LACKEY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 JFK BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-8247
Mailing Address - Country:US
Mailing Address - Phone:501-712-4333
Mailing Address - Fax:501-712-4333
Practice Address - Street 1:3801 JFK BLVD STE C
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116
Practice Address - Country:US
Practice Address - Phone:501-712-4333
Practice Address - Fax:501-712-4333
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2939225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist