Healthcare Provider Details

I. General information

NPI: 1295374585
Provider Name (Legal Business Name): KELLY EILEEN LACKEY MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2020
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 CHAPMAN RD STE 201
NEWARK DE
19702-5415
US

IV. Provider business mailing address

12 ADELENE AVE
NEWARK DE
19711-5570
US

V. Phone/Fax

Practice location:
  • Phone: 302-292-1334
  • Fax:
Mailing address:
  • Phone: 302-292-1334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: