MEDICARE: MR. RODNEY MERLIN LACKEY LCSW

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	1041C0700X	Clinical Social Worker	328	CA

General Provider Information

NPI Number	:	1649496738
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RODNEY MERLIN LACKEY LCSW

Provider Business Mailing Address
First Line	:	5919 RANCHITO AVE
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91401-4349
Country	:	US
Telephone Number	:	818-424-8280
Fax Number	:	818-782-5649

Provider Business Practice Location Address
First Line	:	3699 WILSHIRE BLVD FL 3
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-2719
Country	:	US
Telephone Number	:	323-782-5649
Fax Number	:

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

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	07/08/2007

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