Healthcare Provider Details

I. General information

NPI: 1689459687
Provider Name (Legal Business Name): ANNACLAIRE LACKNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257A COUNTY ROAD 40
SULLIVAN OH
44880-9731
US

IV. Provider business mailing address

1412 RIDGEWOOD AVE APT 1
LAKEWOOD OH
44107-5059
US

V. Phone/Fax

Practice location:
  • Phone: 419-736-3300
  • Fax:
Mailing address:
  • Phone: 513-498-7324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberCOND.20232581-SP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: