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NPI Code Detail

MEDICARE: MARY KELLY MOORE LACKEY LPC

MEDICARE: MARY KELLY MOORE LACKEY LPC
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
1101YM0800XMental Health CounselorLPC04635OK
2101YP2500XProfessional CounselorLPC04635OK

General Provider Information

NPI Number : 1326200437
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARY KELLY MOORE LACKEY LPC
Provider Business Mailing Address
First Line : 4013 NW EXPRESSWAY STE 105
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73116-2618
Country : US
Telephone Number : 405-378-2727
Fax Number :
Provider Business Practice Location Address
First Line : 4013 NW EXPRESSWAY STE 105
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73116-2618
Country : US
Telephone Number : 405-378-2727
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/30/2008
Last Update Date : 01/15/2025

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Directions to “ MARY KELLY MOORE LACKEY LPC” Practice Location

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