Basic Information
| Provider Information | |||||||||
| NPI: | 1780090506 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACKEY | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | KATELYN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 WISTERIA DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300782689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709820102 | ||||||||
| FaxNumber: | 7709820130 | ||||||||
| Practice Location | |||||||||
| Address1: | 429 LOGANVILLE HWY STE 110 | ||||||||
| Address2: | |||||||||
| City: | WINDER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306805630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703188030 | ||||||||
| FaxNumber: | 7703188031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2014 | ||||||||
| LastUpdateDate: | 11/15/2019 | ||||||||
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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 | 225100000X | PT011462 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.