Provider Demographics
NPI:1124636808
Name:LACKARD, ALVIN DAVE
Entity type:Individual
Prefix:
First Name:ALVIN
Middle Name:DAVE
Last Name:LACKARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 MARYLAND ST APT 2
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-4165
Mailing Address - Country:US
Mailing Address - Phone:860-938-7205
Mailing Address - Fax:
Practice Address - Street 1:3313 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2691
Practice Address - Country:US
Practice Address - Phone:617-522-7008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor