Provider Demographics
NPI:1962124842
Name:LACKEY, LESLIE ALLISON (CCC-SLP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ALLISON
Last Name:LACKEY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 COUNTY ROAD 3000
Mailing Address - Street 2:
Mailing Address - City:DODD CITY
Mailing Address - State:TX
Mailing Address - Zip Code:75438-3222
Mailing Address - Country:US
Mailing Address - Phone:903-640-6244
Mailing Address - Fax:
Practice Address - Street 1:321 S 2ND ST
Practice Address - Street 2:
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418-4701
Practice Address - Country:US
Practice Address - Phone:903-640-6244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108996235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist