Provider Demographics
NPI:1457812307
Name:LACKIE, BRETT DAVID (DPT)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:DAVID
Last Name:LACKIE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10707 DIRECT RIVER DR NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3922
Mailing Address - Country:US
Mailing Address - Phone:612-385-4956
Mailing Address - Fax:
Practice Address - Street 1:300 LAKE DR E
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-9302
Practice Address - Country:US
Practice Address - Phone:952-993-4300
Practice Address - Fax:952-993-4320
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11403225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist