Healthcare Provider Details

I. General information

NPI: 1013269760
Provider Name (Legal Business Name): KELLI ELLEN LACKETT MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2012
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1148 E ELIZABETH ST
FORT COLLINS CO
80524-4068
US

IV. Provider business mailing address

1148 E ELIZABETH ST
FORT COLLINS CO
80524-4068
US

V. Phone/Fax

Practice location:
  • Phone: 970-472-4133
  • Fax: 970-493-6655
Mailing address:
  • Phone: 970-472-4133
  • Fax: 970-493-6655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: