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Provider Information for 1568658557


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Mr. HORACE GRADY LACKEY III LPC


Sex: Male

NPI: 1568658557
Last Updated: 2007-09-24
Certification Date:

Details

NameValue
NPI1568658557
Enumeration Date2007-09-24
NPI TypeNPI-1 Individual
Sole ProprietorYES
StatusActive
Mailing Address 1701 RIVER RUN STE 305
FORT WORTH, TX 76107-6576
United States

Phone: 817-991-9194 | Fax:
 
Primary Practice Address 1701 RIVER RUN STE 305
FORT WORTH, TX 76107-6576
United States

Phone: 817-991-9194 | Fax:
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
MEDICAIDTX179908201
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
Yes 101YP2500X - Counselor - ProfessionalTX16721