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NPI Code Detail

MEDICARE: KELLI ELLEN LACKETT MS

MEDICARE: KELLI ELLEN LACKETT MS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106H00000XMarriage & Family Therapist

General Provider Information

NPI Number : 1013269760
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLI ELLEN LACKETT MS
Provider Business Mailing Address
First Line : 1148 E ELIZABETH ST
Second Line :
City : FORT COLLINS
State : CO
Zip : 80524-4068
Country : US
Telephone Number : 970-472-4133
Fax Number : 970-493-6655
Provider Business Practice Location Address
First Line : 1148 E ELIZABETH ST
Second Line :
City : FORT COLLINS
State : CO
Zip : 80524-4068
Country : US
Telephone Number : 970-472-4133
Fax Number : 970-493-6655
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/04/2012
Last Update Date : 10/04/2012

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Directions to “ KELLI ELLEN LACKETT MS” Practice Location

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