Healthcare Provider Details

I. General information

NPI: 1316117831
Provider Name (Legal Business Name): MOLLIE D LACKEY LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MOLLIE D DELAWDER LSW

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 PRIVATE ROAD 977
PEDRO OH
45659-8608
US

IV. Provider business mailing address

115 PRIVATE ROAD 977
PEDRO OH
45659-8608
US

V. Phone/Fax

Practice location:
  • Phone: 740-534-1386
  • Fax: 740-534-1497
Mailing address:
  • Phone: 740-534-1386
  • Fax: 740-534-1497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberS-0028697
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1100136-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: