Provider Demographics
NPI:1427321314
Name:LACKO, KRISTY L (PSYD)
Entity type:Individual
Prefix:DR
First Name:KRISTY
Middle Name:L
Last Name:LACKO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 STANLEY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-2636
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3800 S W S YOUNG DR STE 407
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-3374
Practice Address - Country:US
Practice Address - Phone:254-252-3748
Practice Address - Fax:254-549-0086
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-22
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24531103TC0700X
TX36749103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical