Healthcare Provider Details

I. General information

NPI: 1083173520
Provider Name (Legal Business Name): LACKAYE THERAPY AND ADVOCACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2019
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2736 N SOUTHPORT AVE APT 1
CHICAGO IL
60614-1230
US

IV. Provider business mailing address

2736 N SOUTHPORT AVE APT 1
CHICAGO IL
60614-1230
US

V. Phone/Fax

Practice location:
  • Phone: 573-356-7909
  • Fax:
Mailing address:
  • Phone: 573-356-7909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JOANNA LACKAYE
Title or Position: OWNER / THERAPIST
Credential: LCSW
Phone: 573-356-7909