Provider Demographics
NPI:1891769907
Name:LACSON, KATHLEEN M (PMHNP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:LACSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832 HANSHAW RD FL 2
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1548
Mailing Address - Country:US
Mailing Address - Phone:917-887-0031
Mailing Address - Fax:607-793-6149
Practice Address - Street 1:832 HANSHAW RD FL 2
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1548
Practice Address - Country:US
Practice Address - Phone:917-887-0031
Practice Address - Fax:607-793-6149
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY430739-1367500000X
NYF401607-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
RB0606Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER