Healthcare Provider Details

I. General information

NPI: 1114165636
Provider Name (Legal Business Name): LAURIE LACK LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2009
Last Update Date: 01/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVENUE ML 6015
CINCINNATI OH
45229-3039
US

IV. Provider business mailing address

3333 BURNET AVENUE ML 5021
CINCINNATI OH
45229-3039
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-0800
  • Fax: 513-636-0810
Mailing address:
  • Phone: 513-636-4255
  • Fax: 513-636-2511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.0007901
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: