MEDICARE: MR. LEE TODD LACKS LCPC-C, MT-BC

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
1	251C00000X	Developmentally Disabled Services Day Training Agency	XL3782	ME
2	251S00000X	Community/Behavioral Health Agency	XL3782	ME

General Provider Information

NPI Number	:	1285918383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LEE TODD LACKS LCPC-C, MT-BC

Provider Business Mailing Address
First Line	:	9 LEMONT AVE
Second Line	:
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-5717
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9 LEMONT AVE
Second Line	:
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-5717
Country	:	US
Telephone Number	:	207-210-6045
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2011
Last Update Date	:	10/06/2011

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