Provider Demographics
NPI:1780360867
Name:LACKOW, JULIETTE ROSE (LMSW)
Entity type:Individual
Prefix:
First Name:JULIETTE
Middle Name:ROSE
Last Name:LACKOW
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 E 82ND ST APT 3W
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-4902
Mailing Address - Country:US
Mailing Address - Phone:973-820-1359
Mailing Address - Fax:
Practice Address - Street 1:352 7TH AVE RM 801
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-5655
Practice Address - Country:US
Practice Address - Phone:646-418-1172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120018104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker