Provider Demographics
NPI:1477387835
Name:LACKEY, JUSTIN DAVID (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DAVID
Last Name:LACKEY
Suffix:
Gender:M
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 E PARK VIEW LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-5302
Mailing Address - Country:US
Mailing Address - Phone:805-338-3361
Mailing Address - Fax:
Practice Address - Street 1:2120 E PARK VIEW LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85024-5302
Practice Address - Country:US
Practice Address - Phone:805-338-3361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ009730225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics