Provider Demographics
NPI:1588465983
Name:LACKS, VONTRISE (LMSW)
Entity type:Individual
Prefix:
First Name:VONTRISE
Middle Name:
Last Name:LACKS
Suffix:
Gender:
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BRONX PSYCHIATRIC CENTER 1500 WATERS PLACE
Mailing Address - Street 2:RM A1-421
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461
Mailing Address - Country:US
Mailing Address - Phone:929-502-0551
Mailing Address - Fax:
Practice Address - Street 1:BRONX PSYCHIATRIC CENTER 1500 WATERS PLACE
Practice Address - Street 2:RM A1-421
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461
Practice Address - Country:US
Practice Address - Phone:929-502-0551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-21
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121892104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker