Provider Demographics
NPI:1265575609
Name:LACKEY, STACY (MS)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:LACKEY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5635 N MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74126-6409
Mailing Address - Country:US
Mailing Address - Phone:918-594-4731
Mailing Address - Fax:918-595-4269
Practice Address - Street 1:5635 N MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74126-6409
Practice Address - Country:US
Practice Address - Phone:918-594-4731
Practice Address - Fax:918-595-4269
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK329231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200065580AMedicaid