Basic Information
| Provider Information | |||||||||
| NPI: | 1114165636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACK | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 BURNET AVENUE | ||||||||
| Address2: | ML 5021 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364255 | ||||||||
| FaxNumber: | 5136362511 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 BURNET AVENUE | ||||||||
| Address2: | ML 6015 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136360800 | ||||||||
| FaxNumber: | 5136360810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2009 | ||||||||
| LastUpdateDate: | 01/22/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | E.0007901 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.