Provider Demographics
NPI:1326200437
Name:MOORE LACKEY, MARY KELLY (LPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KELLY
Last Name:MOORE LACKEY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4013 NW EXPRESSWAY STE 105
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-2618
Mailing Address - Country:US
Mailing Address - Phone:405-378-2727
Mailing Address - Fax:
Practice Address - Street 1:4013 NW EXPRESSWAY STE 105
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-2618
Practice Address - Country:US
Practice Address - Phone:405-378-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLPC04635101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health